Ultrasonographic screening for developmental dysplasia of the hip: the Graf method revisited.

Until the 1980s, the diagnosis of developmental dysplasia of the hip (DDH) was based on clinical examination and radiographic imaging. In 1980, Reinhard Graf developed his own ultrasonographic method for the examination of the infant hip joint. Graf's method evaluates the osseous and cartilaginous coverage of the femoral head by the acetabulum in the infantile hip joint by measuring the angles α and ß. The validity of Graf method is that with these measurements the hip joint is further classified by Graf classification into types I to IV that guide treatment. Currently, Graf method is considered the gold standard examination for the diagnosis of DDH in many European countries. This review article aims to discuss the incidence, risk factors and pathophysiology of DDH, and to emphasize on the Graf method for the evaluation, classification, prevention and further management of this entity.

What do hip fracture patients die from?

Hip fractures in the elderly are associated with an increased mortality rate, even if they are operated within the recommended time window. However, the causes of mortality vary considerably depending on the postoperative period and the patients' comorbidities. In the 30-day postoperative period, the most common causes of death are acute processes such as bacterial and aspiration pneumonia followed by myocardial infarction, cancer, gastrointestinal hemorrhage, stroke, pulmonary embolism, and acute renal failure. In the 6-month and 1-year postoperative period, chronic processes appear to be the most important causes of death, as well as decompensation of patients' chronic diseases. To enhance the literature, we performed this literature review to summarize and discuss the causes of mortality of elderly hip fracture patients depending on the postoperative period that they occur, and possibly to address the question what do hip fracture patients die from? Our aim was to perform an interesting and concise paper that the curious reader will find interesting and informative.

Cross-cultural adaptation and validation of the Musculoskeletal Tumor Society (MSTS) scoring system and Toronto Extremity Salvage Score (TESS) for musculoskeletal sarcoma patients in Greece.

PURPOSE: To perform translation, cross-cultural adaptation, and validation of the Toronto Extremity Salvage Score (TESS) and Musculoskeletal Tumor Society (MSTS) scoring system in Greek patients with lower extremity sarcoma. METHODS: The Greek version of the MSTS for the lower extremity and TESS questionnaires was developed using previously reported methods. Included were 100 patients with musculoskeletal sarcoma who underwent limb salvage surgery. The test-retest reliability [interclass correlation coefficient (ICC) between 2 different time points], internal consistency (Cronbach's alpha), construct validity (Kaiser's criteria, Eigenvalue > 1 rule), and external validity (Short form-36, Spearman's Rho) were assessed. RESULTS: The test-retest reliability (ICC was 0.99 for MSTS-LE and 1 for TESS) and internal consistency were high (Cronbach's alpha was 0.763 for MSTS-LE and 0.924 for TESS) for both questionnaires. Based on the Scree plot, the number of factors retained was 1 for MSTS-LE and 2 for TESS. The TESS showed a strong correlation with SF-36 (Spearman's rho = 0.714, p < 0.001), but the correlation between MSTS for lower extremity and SF-36 was weak (Spearman's Rho = 0.313, p = 0.002). CONCLUSIONS: The Greek version of both the MSTS for lower extremity and TESS questionnaire showed sufficient reliability, internal consistency and good performance using the loading factor analysis when used postoperatively in Greek patients who underwent surgical resection of lower extremity sarcoma. However, only the TESS showed strong correlation with the SF-36, indicating that MSTS for lower extremity was not as powerful for the evaluation of the global health status of these patients.

Similar 2-point discrimination and stereognosia but better locognosia at long term with an independent home-based sensory reeducation program vs no reeducation after low-median nerve transection and repair.

STUDY DESIGN: Prospective controlled study. INTRODUCTION: Previous studies evaluated the effectiveness of sensory reeducation (SR) after peripheral nerve injury and repair. However, evidence for long-term clinical usefulness of SR is inconclusive. PURPOSE OF THE STUDY: The purpose of this study is to compare the sensory results of patients with low-median nerve complete transection and microsurgical repair, with and without SR at long term. METHODS: We prospectively studied 52 consecutive patients (mean age, 36 years; range, 20-47 years) with low-median nerve complete transection and microsurgical repair. When reinnervation was considered complete with perception of vibration with a 256-cycles per second tuning fork (mean, 3.5 months after nerve injury and repair), the patients were sequentially allocated (into 2 groups [group SR, 26 patients, SR; group R, 26 patients, reassured on recovery without SR). SR was conducted in a standardized fashion, in 2 stages, as an independent home-based program: the first stage was initiated when reinnervation was considered complete, and included instruction in home exercises to identify familiar objects and papers of different roughness, and localization of light touch (eyes open and closed); the second stage was initiated when the patients experienced normal static and moving 2-point discrimination (2PD) at the index fingertip of injured hand, and included instruction in home exercises for stereognosia, supplementary exercises for localization of light touch, and identification of small objects (eyes open and closed). Exercises were prescribed for 5-10 minutes, 4 times per day. At 1.5, 3, and 6 years after nerve injury and repair, we evaluated the static and moving 2PD, stereognosia with the Moberg's pick-up test, and locognosia with the modified Marsh test. Comparison between groups and time points was done with the nonparametric analysis of variance (Kruskal-Wallis analysis of variance). RESULTS: Static and moving 2PD and stereognosia were not significantly different between groups at any study period. Locognosia was significantly better at 1.5 and 3 years in group SR; locognosia was excellent in 17 patients of group SR vs 5 patients of group R at 1.5-year follow-up and in 14 patients of group SR vs 5 patients of group R at 3-year follow-up. Locognosia was not different between the study groups at 6-year follow-up. CONCLUSION: A 2-stage home program of SR improved locognosia at 1.5 and 3 years after low-median nerve complete transection and repair without significant differences in other modalities or the 6-year follow-up of a small subsample.

Peroneal nerve palsy after ankle sprain: an update.

Ankle sprains are extremely common in the general population and the most common injuries in athletes. Although rare, peroneal nerve palsy may occur simultaneously with ankle sprain. The exact incidence of nerve injury after ankle sprain is not known; few cases of peroneal nerve palsy associated with ankle sprains have been reported in the literature. The function of the peroneal nerve should be evaluated in all patients with a history of inversion ankle sprain as part of the initial and follow-up evaluation, even if the initial neurological status is normal, because delayed peroneal nerve palsy is possible. This article discusses the incidence, pathophysiology, evaluation, diagnosis and differential diagnosis, and management of the patients with peroneal nerve palsy after ankle sprain aiming to increase the awareness of the treating physicians for this nerve injury.

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.

The History of Orthopedics in the Long Term: From General Medicine to Medical Specialties.

A thorough literature search was done in PubMed and Google Scholar as well as in physical books in libraries to summarize the literature on the history and evolution of medicine and orthopedics. The philosophical ideas that emerged in ancient Greece served as a foundation for the development of medicine. In the 5th century BC, the schools of Knidos and Kos emerged as influential centers for the development of medical thinking. The field of orthopedics can be traced back to early human civilizations. Ancient Egyptians perpetuated the tradition of employing splinting techniques. Hippocrates provided insights for the diagnosis, correction and treatment of many musculoskeletal entities. The field of medicine experienced a period of limited advancement during the Middle Ages. The Renaissance provided for the foundation of modern orthopedics and important contributions to the understanding and implementation of antisepsis. The discovery of x-ray and advancements in infection control and anesthesia have shown substantial progress in the domain of orthopedics and have contributed to the development of orthopedic subspecialization. Orthopedic surgery holds a historical lineage deeply entrenched in ancient practices and early human civilizations. Physicians specializing in orthopedics should be aware of the historical origins of their discipline and continue to evolve through further subspecialization and enhanced research.

Acute lumbosacral plexopathy from gluteal compartment syndrome after drug abuse: a case report.

Acute lumbosacral plexus injury from gluteal compartment syndrome is extremely rare. Physicians should be aware of this diagnosis when examining patients with altered mental status, prolonged immobilization, and gluteal muscle compression. This case report presents a patient with acute complete left lumbosacral plexus paralysis and acute renal failure after gluteal compartment syndrome secondary to prolonged immobilization from drug abuse. Clinical examination, imaging of the pelvis, renal function, creatine phosphokinase, and urine myoglobin were indicative of gluteal compartment syndrome and rhabdomyolysis. Electrodiagnostic studies showed complete limb paralysis. Medical treatment and rehabilitation was administered. Renal function recovered within the 1st week; function at the proximal muscles of the left lower limb improved within 6 months, with mild discomfort on sitting at the buttock, foot drop, and sensory deficits at the leg and dorsum of foot.

Sagittal alignment of the cervical spine after neck injury.

The normal sagittal alignment of the cervical spine is lordotic and is affected by the posture of the head and neck. The question of whether loss of cervical lordosis is the result of muscle spasm after injury or a normal variation, and the clinical significance of such changes in sagittal profile of the cervical spine has been an issue of several studies. The purpose of this paper is to study the incidence of normal cervical lordosis and its changes after neck injury compared to the healthy population. We studied the lateral radiographs of the cervical spine of 60 patients with neck injury compared to 100 patients without a neck injury. Lateral radiographs were obtained in the standing or sitting position, and the curvature of the cervical spine was measured using the angle formed between the inferior end plates of the C2 and C7 vertebrae. In the patients without neck injury, lordotic and straight cervical spine sagittal alignment was observed in 36.5% each, double curvature in 17%, and kyphotic in 10%. In the patients with neck injury, lordotic sagittal alignment was observed in 36%, straight in 34%, double curvature in 26% and kyphotic in 4%. No significant difference between the two groups regarding all types of sagittal alignment of the cervical spine was found (p > 0.100). The alterations in normal cervical lordosis in patients with neck injury must be considered coincidental. These alterations should not be associated with muscle spasm caused by neck pain.

Adipose-Derived Stem Cells and Tacrolimus Improve Nerve Regeneration in a Rat Sciatic Nerve Defect Model.

This study compared the effect of undifferentiated adipose-derived stem cells (ADSCs) vs tacrolimus (FK506) in peripheral nerve regeneration in a rat sciatic nerve complete transection model. Forty Wistar rats were equally distributed in four groups. In the SHAM surgery group, the sciatic nerve was exposed and no further intervention was done. In the conduit-alone group (the SLN group), a 10-mm nerve gap was created and bridged with a fibrin conduit filled in with normal saline. In the FK506 group, the fibrin conduit was injected with soluble FK506. In the ADSC group, the conduit was impregnated with undifferentiated ADSCs. Nerve regeneration was assessed by means of walking track analysis, electromyography, and neurohistomorphometry. Clinically and microscopically, nerve regeneration was achieved in all groups at 12 weeks. Walking track analysis confirmed functional recovery in the FK506 and ADSC groups, but there was no difference between them. Recovery in function was also achieved in the SLN group, but it was inferior (P<.05). Electromyography demonstrated superior nerve regeneration in the FK506 and ADSC groups compared with the SLN group (P<.05), with no difference between the FK506 and ADSC groups. Similarly, histology showed no difference between the FK506 and ADSC groups, although both outperformed the SLN group (P<.05). No complications were observed. Successful peripheral nerve regeneration can be accomplished after a 10-mm nerve defect treated with nerve conduits. Superior nerve regeneration may be expected when the conduits are loaded with undifferentiated ADSCs or FK506, with similar outcomes for ADSCs and FK506. [Orthopedics. 2023;46(6):e353-e361.].

Common peroneal nerve palsy after grade I inversion ankle sprain.

This case report presents a 28-year-old man with foot drop 48 hours after a grade I inversion ankle sprain. Clinical examination and electrodiagnostic studies showed common peroneal nerve palsy. The patient was managed with conservative treatment and rehabilitation and recovered completely 4 months after the injury. Physicians should be aware of the possibility of delayed peroneal nerve injury after grade I ankle sprain. Function of the peroneal nerve should be evaluated in all patients with inversion ankle sprain as part of initial and follow-up evaluations. Early electrodiagnostic studies are helpful to localize and provide indications of the severity of the injury.

The Influence of Sepsis on the Molecular Structure of Bones: A Fourier Transform Infrared Spectroscopy Study.

Fourier transform infrared spectroscopy was used to evaluate the molecular structure of bone tissues of patients who underwent revision of total hip and shoulder arthroplasty. The intensity increase of the spectral bands in the region of 3000-2850 cm-1 provided information about the increase of the lipophilic environment, which supported the formation of aggregates and amyloid protein formation. The appearance and the intensity increase of the "marker band" at 1744 cm-1 suggested protein peroxidation and inflammation progression. The shift of the amide I and amide II absorption bands from 1650 cm-1 and 1550 cm-1, respectively, to lower frequencies was related to changes of collagen conformation structure from α-helix to ß-sheet and random coil. The appearance and shifts of the new bands in the region 1200-900 cm-1 were related with the increasing of glycosylation upon inflammation. Important was also the disappearance of the hydroxyapatite vPO43- absorption bands at the spectral regions 1200-900 cm-1 and 550-650 cm-1 indicated the osteolysis development. Moreover, the formation of corrosive metallic implants confirmed the effect of oxidative stress on the development of periprosthetic joint infection.

Birth fracture of the clavicle.

Birth fracture of the clavicle occurs in approximately 0.4% to 10% of vaginal births. The most common symptom is decreased movement of the ipsilateral arm. A high index of suspicion is necessary in infants presenting without any symptoms. Although displaced clavicular fractures are relatively easily diagnosed clinically, nondisplaced fractures may be apparent only after callus formation, or if all neonates are subjected to radiography or ultrasonography, or multiple physical examinations by trained examiners. We present a case of an infant delivered with vaginal labor with a fracture of the right clavicle diagnosed after apparent callus formation and discuss the current evidence of associated factors and obstetrical care.

Acute renal failure in orthopaedic surgery.

Orthopaedic diseases affect a broad spectrum of patients, and many of these have concomitant medical problems that may differ from those of the general surgical population. Acute postoperative renal failure is thought to arise secondary to acute tubular necrosis from volume depletion, reduction in glomerular filtration rate, hypotension, and nephrotoxic drugs. If acute renal failure occurs and necessitates hemodialysis, morbidity and mortality are significantly increased. To enhance the literature, we performed this study to review the rates and risk factors for acute renal failure in orthopaedic surgery. This information may be useful for orthopaedic surgeons and treating physicians during the rehabilitation stage, to provide a rationale to stratify a patient's risk of acute renal failure or death on the basis of perioperative medical factors and type of surgery, or for improved perioperative monitoring, better surveillance, and preventive measures to reduce this risk.

Evidence-based evaluation and current practice of non-operative treatment strategies for lumbar stenosis.

OBJECTIVE: A number of non-operative treatment protocols have been proposed in the literature for lumbar stenosis. However, the available primary research describes inadequately the employed protocol. This causes difficulties in distinguishing which interventions are more effective in reducing symptoms. METHODS: We reviewed existing studies in order to promote the construction of an evidence-based strategy for non-operative treatment rehabilitation of lumbar stenosis patients. Randomized controlled trials describing insufficiently the non-operative treatment rehabilitation protocols were excluded since the results may not direct this review towards a favorable treatment plan. RESULTS: A protocol has been outlined to inform the clinician and to elucidate the effectiveness of non-operative treatment through randomized controlled trials. The results of this study indicate that a comprehensive exercise and manual therapy protocol is more effective in reducing symptoms than a less intensive exercise program. CONCLUSIONS: A comprehensive non-operative treatment comprising of flexion exercises, manual therapy and treadmill exercises appears to be more beneficial in reducing symptoms than a less vigorous program comprising of flexion exercises, treadmill training and home exercise.

Surgical outcome of scaphoid nonunions in heavy manual workers.

The management of scaphoid nonunion in heavy manual workers is challenging. Symptoms appear earlier and manual labor-related stress at the operated nonunion site may worsen the postoperative outcome. This study involved 16 heavy manual workers with scaphoid nonunion (11 cases involving the dominant hand) treated by internal fixation and autologous bone grafting. The nonunion was in 12 patients in the waist, in 3 patients in the proximal, and in 1 patient in the distal pole of the scaphoid. Clinical and radiographic evaluation of union was done according to the criteria of Bynum et al. and Fernandez and Eggli. Pain, wrist motion, and grip strength were evaluated and compared to the contralateral side. At a mean follow-up of 24 months (range, 10 months to 6 years), the mean range of motion and the grip strength compared to the contralateral hand were 95% and 91%, respectively. Overall hand function was excellent in 13 patients, good in 2 patients, and fair in 1 patient. All except one patient were pain free and returned to their work without or with minimal complaints at an average of 3.4 months (range, 2-6 months), postoperatively. In 15 patients, scaphoid nonunions healed at a mean time of 64 days. One patient had a reoperation, and union was observed at 90 days after the second operation. In all patients, the radiolunate angle was restored to normal. One patient developed complex regional pain syndrome that resolved completely after 2 months with adequate intensive physical therapy. Clinical symptoms of scaphoid nonunions are more severe and appear earlier in heavy manual workers; in this group of patients, surgical treatment is necessary. The double-threaded screw provides adequate stabilization for union. Autologous cancellous bone graft, because of its plasticity and malleability to exactly fill the scaphoid defect, is recommended.

Ultrasonography Provides a Diagnosis Similar to That of Nerve Conduction Studies for Carpal Tunnel Syndrome.

Carpal tunnel syndrome (CTS) is the most common peripheral entrapment neuropathy. Its diagnosis is based on clinical symptoms and neurophysiological evaluation. Recently, ultrasonography has been introduced as a promising noninvasive diagnostic alternative. In this study, the authors compared ultrasonography with neurophysiological findings for the diagnosis of CTS in 96 patients/hands with clinical symptoms of CTS. The latency, amplitude, distance, and velocity of the median and ulnar nerves were measured. Needle electromyography was performed in the abductor pollicis brevis, in addition to muscles of the arm and forearm, to exclude proximal median nerve, brachial plexus, or radicular abnormalities. Ultrasonography was based on the morphologic/anatomic changes of the median nerve cross-sectional area in the sagittal plane of the wrist at the level of the pisiform bone, the changes of its regional echogenicity, and the identification of coexisting pathologies, such as tenosynovitis, space-occupying lesions, supplementary muscles, and vessels, that may provoke indirectly an increase of the pressure in the carpal tunnel. Eighty-seven (90%) of the 96 patients/hands with clinical symptoms of CTS showed positive findings in both ultrasonography and nerve conduction studies. Six (6%) patients showed positive findings only in nerve conduction studies, and 3 (3%) patients showed positive findings only in ultrasonography; the difference was not statistically significant. The sensitivity and the specificity of nerve conduction studies compared with ultrasonography was 97% and 89% compared with 94% and 55%, respectively. A positive correlation and proportional increase of the ultrasonography measurements compared with the increase of the nerve conduction studies severity was observed. [Orthopedics. 2019; 42(5):e460-e464.].

High tibial osteotomies: indications and techniques.

The rationale, definition, and techniques of high tibial osteotomies are discussed. The principle indication includes unicompartmental medial or varus knee gonarthrosis with a well-maintained range of motion. Preservation of bone stock and intraarticular structures and realignment during chondral resurfacing procedures are the major advantages of high tibial osteotomies. Newer techniques have provided for less invasive surgical methods, more rigid fixation, accelerated rehabilitation, and improved accuracy of correction for high tibial osteotomies. However, permanent pain relief with high tibial osteotomies is unlikely; overall survival approximates 8 to 10 years. Subsequent conversion to a total knee arthroplasty may at times be technically demanding but the long-term results are likely to be similar to a primary total knee replacement.

Thromboembolism prophylaxis in orthopaedics: an update.

Venous thromboembolism (VTE) is a serious complication during and after hospitalization, yet is a preventable cause of in-hospital death.Without VTE prophylaxis, the overall VTE incidence in medical and general surgery hospitalized patients is in the range of 10% to 40%, while it ranges up to 40% to 60% in major orthopaedic surgery. With routine VTE prophylaxis, fatal pulmonary embolism is uncommon in orthopaedic patients and the rates of symptomatic VTE within three months are in the range of 1.3% to 10%.VTE prophylaxis methods are divided into mechanical and pharmacological. The former include mobilization, graduated compression stockings, intermittent pneumatic compression device and venous foot pumps; the latter include aspirin, unfractionated heparin, low molecular weight heparin (LMWH), adjusted dose vitamin K antagonists, synthetic pentasaccharid factor Xa inhibitor (fondaparinux) and newer oral anticoagulants. LMWH seems to be more efficient overall compared with the other available agents. We remain sceptical about the use of aspirin as a sole method of prophylaxis in total hip and knee replacement and hip fracture surgery, while controversy still exists regarding the use of VTE prophylaxis in knee arthroscopy, lower leg injuries and upper extremity surgery. Cite this article: EFORT Open Rev 2018;3:136-148. DOI: 10.1302/2058-5241.3.170018.

Similar function and complications for patients with short versus long hip nailing for unstable pertrochanteric fractures.

PURPOSE: To compare short with long intramedullary hip nailing for elderly patients with unstable pertrochanteric fractures. METHODS: We prospectively studied 50 patients (33 women, 17 men; mean age, 80 years; range, 74-93 years) with unstable pertrochanteric fractures admitted and treated with a short (group A) or a long (group B) intramedullary hip nail from January 2013 to 2017. The patients were randomly allocated into each group according to their order of admission. The mean follow-up was 2 years (range, 1-5 years). We evaluated operative time, function, fracture healing, varus/valgus loss of reduction, and distance between the distal line of the fracture and the distal locking screw of the nail. RESULTS: Operative time was significantly shorter in group A. Function, fracture healing and varus/valgus loss of reduction was similar between the two groups. The mean distance between the distal fracture line and distal locking screw was 7.2 cm (range, 3-10 cm) in patients of group A; in all patients of group B, an appropriate nail length was chosen so that the distal locking screw was inserted at least 3 times the diameter of the bone at the distal fracture line. Complications included periprosthetic fracture (one patient of group A), and z-effect phenomenon (one patient of group B); complications rate was similar between the two groups. CONCLUSION: Short intramedullary hip nailing is associated with similar function and complications, but shorter operative time compared to long intramedullary hip nails for patients with unstable pertrochanteric fractures.