Complications Following Short Femoral Nail Fixation for Intertrochanteric Hip Fractures: A Retrospective Study.

The incidence of proximal femur fractures is increasing due to aging of the population. Intramedullary nails are the mainstay of treatment for intertrochanteric hip fractures mainly due to their better biomechanical properties compared to dynamic hip screw devices, shorter operative time, and less blood loss during surgery. However intramedullary nail fixation is not devoid of complications. The purpose of this study is to look at complications related to intramedullary nailing for intertrochanteric hip fractures in a major trauma center. A retrospective study was conducted including all patients having suffered an intertrochanteric femur fracture and treated with intramedullary nails from October 1, 2020, to October 1, 2022, in the Orthopaedic Surgery Clinic. The intramedullary hip systems used were the Stryker Gamma3 Nail and the VITUS PF Nail. All complications following the postoperative period were recorded in detail. Overall, 240 patients with a mean age of 82.3 years treated with hip intramedullary devices were identified. Superior cutout of the lag screw in two patients (females 90 and 87 years old) was identified 8 and 10 weeks following initial surgery. Avascular necrosis (AVN) of the femoral head was identified in one patient (male 81 years old) which occurred 12 weeks postoperatively. All three cases were revised by replacing the nail with cemented hemiarthroplasty. Periprosthetic fractures occurred in an 88-year-old male and a 73-year-old female following an injury distal to the stem and were managed by replacing the nail with a long stem device (Long Gamma3). One case of metalwork fracture was also recorded. There are many advantages in managing intertrochanteric hip fractures with intramedullary hip devices such as shorter theater time, less blood loss, and improved biomechanical properties. However, complications such as cutout of the lag screw, AVN, and periprosthetic fracture are serious and require complex revision surgery.

The Impact of COVID-19 Pandemic in Orthopaedic Surgery Hospital Admissions and Workload in a Major Trauma Center.

The coronavirus disease 2019 (COVID-19) pandemic has led to important restrictions in social life of civilians worldwide and there were lower admission rates mainly in surgical departments in many hospitals. This study presents how COVID-19 pandemic affected admissions at the orthopaedic and trauma surgery department of a major trauma center. A retrospective study was conducted that recorded all patients examined at the outpatient orthopaedic clinic and the emergency orthopaedic department, as well as patients admitted to the orthopaedic surgery clinic and patients that underwent operative procedures between March 23 and May 4, 2020 (first lockdown period) and between March 23 and May 4, 2019 (control period). In addition, all patients with hip fractures that required hospitalization and underwent hip surgery were identified during the same time periods. During lockdown period 1 compared with the lock-down period 2 were observed: 70% and 61% decrease in the number of patients examined at the outpatient clinic and the emergency orthopaedic department respectively. The number of patients admitted to the orthopaedic surgery clinic declined by 41%, whereas operative procedures decreased by 22%. Regarding hip fractures timing to surgery during the first period was significantly less compared with second lockdown period, however, hospitalization days remained almost unchanged over the two time lockdown periods. Restrictions during the first lockdown period due to COVID-19 pandemic caused an important decrease in the number of patients and theaters in all orthopaedic departments in one of the major trauma centers in Athens. However, the incidence of hip fractures in elderly was not significantly decreased. Further similar studies are needed to identify variations and patterns of these parameters in other trauma centers.

Is CT-A Always Reliable in Detecting Active Bleeding in Closed Pelvic Fractures? Management of a Case with Multiple Closed Pelvic Fratures and Internal Iliac Artery Bleeding.

One of the most important complications of pelvic injuries is hemorrhage which can be attributed to the venus plexus of the pelvis, the damaged bone on the fracture site, or in 15% of cases to arterial cause. In the last case mortality could reach 70%. Clinical case presentation, a 77-year-old man, presented in the emergency department of our hospital hemodynamically unstable due to fall from height (3 meters) with comminuted bilateral fractures of the pubic rami, right sacral and iliac wing fracture, right acetabular fracture, fractures of transverse processes of the first, second, and fifth lumbar spine vertebrae and a periprothetic fracture of the right femur. Advanced trauma life support (ATLS) protocol was followed throughout. Computed tomography (CT) scans and CT angiography performed, showed the above mentioned pelvic fractures that did not require stabilization, without further injuries, and a well described retroperitoneal hematoma without any evidence of active bleeding. During the resuscitation process the patient developed cardiac arrest and cardiopulmonary resuscitation (CPR) protocol was followed. The patient was intubated and retained his cardiac rhythm. However, he remained unstable and an angiography was then performed that revealed internal iliac artery bleeding and embolism of the internal iliac artery was performed. The patient was stabilized and was transferred to the intensive care unit for further management. Arterial hemorrhage due to pelvic injury is less common, however presents with high rates of mortality. CT angiography may in some cases not reveal existing active bleeding, misleading the clinician. Therefore, in patients with high clinical suspicion of arterial pelvic hemorrhage who remain unstable during the initial resuscitation and do not present with other primary source of bleeding, an angiography and embolism should be performed as soon as possible.

Surgical Removal of Bone Bridge and Interposition of the Extensor Digitorum Brevis in the Treatment of Calcaneonavicular Coalition in Pediatric Patients: A Case Series, Short Review, and Commentary.

This study retrospectively presents a single-clinic case series of pediatric patients with calcaneonavicular coalition treated by surgical removal of the bone bridge and interposition of the extensor digitorum brevis. This technique is currently the most cited and utilized protocol in operative treatment. Clinical, functional, and radiological results are analyzed and compared with related research. This is a single-clinic retrospective study, conducted for a period of 15 years. One independent investigator reviewed medical records and conducted a de-identified preoperative, inpatient, and postoperative assessment focused on demographic data, history and clinical evaluation, imaging assessment, American Orthopedic Foot and Ankle Society (AOFAS) scoring, and complication analysis. Of 34 patients, 13 met the inclusion criteria. Mean patient age was 11.2 years; 10 were males and 3 were females. Pathology concerned the right lower limb in eight cases and the left in five. Mean time between diagnosis and surgical intervention was 4.3 months and mean postoperative follow-up was 27.2 months. Thorough overview of reported symptoms, identified signs, imaging evaluation, functional outcomes, and adverse effects was performed. Bone bridge removal and interposition of the extensor digitorum brevis is an effective method of treating the condition. Despite drawbacks, results are comparable or even, to some degree, superior to other techniques.

Variations of Ulnar Nerve in the Forearm and Hand: A Review of the Literature and Clinical Significance.

The ulnar nerve originates from the anterior division of the lower trunk of the brachial plexus which continues as the medial cord and gives off branches to the forearm and the hand with motor and sensory fibers. The objective of the current study is to assemble the recognized anatomical variations of the ulnar nerve (UN) and underline their clinical impact. A literature search was undertaken via PubMed database, using the term: "ulnar nerve AND variations." Classical anatomical textbooks were also used for the normal anatomy of the UN. A total of 23 articles met the inclusion criteria, 16 of which are included in this review. Fifty-four additional articles provided useful information according to the aim of this review. Of great interest is the communication between the UN and the radial nerve (RN) in the forearm, as well as the communication between the UN and the median nerve (MN) in both forearm and hand. Furthermore, variations of the UN were observed in the hand and the classification of the UN compression was also described according to the point of the neuropathy. These collecting data are categorized into five tables. Additional aberrations were also included in this review. According to literature, the UN is characterized by numerous variations of its course and branches. Therefore, good knowledge of the normal anatomy is essential. Moreover, the anomalies are of particular importance due to their significant clinical implications and should be taken into consideration by the surgeons during surgical procedures in this region.

Distraction Osteogenesis Technique for the Management of a Gustillo Type I Tibial Shaft Fracture Initially Managed with an Intramedullary Nail Device.

Fractures of the tibia shaft are the most common long bone fractures, especially in young male adults. Due to specific anatomical features, these fractures are more common than any other long-bone fracture. This is one of the main reasons they are associated with twice the incidences of deep infection compared with any other bone and can be combined with the presence of segmental bone defect. Many reconstruction techniques have been used to manage such cases, including Ilizarov technique, Masquelet technique, vascularized fibula transfer, and the monolateral external fixator. We present a case of a 21-year-old male patient who was admitted to our hospital for a Gustillo type I tibial shaft fracture which was initially treated by an intramedullary nail device. Two months postsurgery the patient presented with clinical signs of infection in the area of the fracture site, confirmed by an osteolytic lesion revealed radiographically. A surgical operation was performed that included a tibial osteotomy proximal to the defected bone, bone excision, and application of a LRS external fixation device. Antibiotic therapy was administrated based grown cultures, and regular follow-up X-ray revaluation was performed. After six months, the bone was radiologically united, the frame was removed, and the leg was protected in a walking boot while the patient used only partial weight bearing. The treatment of segmental bone defects associated with infection and soft tissue loss presents a great challenge, and the choice of the appropriate method requires further study.

Fusobacterium Nucleatum Causing Necrotizing Fasciitis of the Neck, Thorax, and Upper Limb: A Lemierre's-Like Case Presentation.

Necrotizing fasciitis (NF) is a rare "flesh-eating" entity with a high mortality rate due to late diagnosis. More specifically, this disease is deemed to be a subset of the aggressive skin and soft tissue infections (SSTIs) resulting in necrosis of the muscle fascia and subcutaneous tissues. It is usually caused by Gram-positive cocci specifically strains of Staphylococcus aureus and Streptococci or the combination of Gram-negative and anaerobic bacteria. If septic thrombophlebitis complicates a parapharyngeal abscess the clinical condition is referred to as Lemierre's syndrome (LS), which is also a rare entity and can result in necrotizing fasciitis of the neck and is usually caused by Fusobacterium necrophorum or Fusobacterium nucleatum. In our study, a rare case of a 61-year-old male patient who presented with progressed necrotizing fasciitis of his neck, chest, as well as his upper arm and a history of a bacterial throat infection in our emergency department is discussed. Despite treatment involving iv antibiotics and urgent radical surgical debridement, the patient unfortunately succumbed to his disease due to sepsis and secondary multiorgan failure.

The Facts and Myths for the Use of Lasers in Orthopedic Surgery.

For the past three decades, laser use has been investigated, mainly on implant applications, as well as hard and soft tissue processing on orthopedics. However, despite significant technological advances and achievements in Biophotonics, lasers have yet to emerge as a successful tool for hard-tissue manipulation (e.g., osseous tissue). Indeed, a careful search in relevant literature reveals a limited number of laser-based clinical applications in orthopedics, except for the low-level laser therapy applications. In this review article, we give a brief overview of the biophysical mechanisms of bone tissue and biocompatible implants laser surgery and, in parallel, we summarize some specific pre-clinical and clinical laser applications in orthopedics. Taking into consideration the complexity of laser-based applications in inhomogeneous musculoskeletal biostructures and/or implants, it is justified to state that applying laser radiation is still an open field of multidisciplinary research before performing interventions in clinical praxis. The evidence from this study indicates the need for more experimental and theoretical studies regarding light transport on soft and hard tissues, in order to further enhance safe and efficient laser applications in orthopedics. This undoubtedly implies the need for developing modern light delivery devices for laser surgery, by means of implementing robotic guidance, specialized for medical procedures on various anatomic structures. The aforementioned studies could eventually revolutionize the clinical applications of laser technology in orthopedics.

Primary Extranodal Skeletal-Muscle Non-Hodgkin B Cell Lymphoma: Clinical Presentation and Diagnostic Approach.

Primary extranodal non-Hodgkin lymphomas that involve skeletal muscles (PSML) are infrequent with non- specific features or symptoms. Therefore, their diagnosis can be immensely convoluted since they mimic other soft tissue tumors and diseases (34). In this study, the case of a 61-year-old male patient, who presented with a history of a 6-week left thigh oedema and concomitant pain in our Emergency Department, is discussed. The patient was initially reviewed in another institution; the results of imaging studies (ultrasound scan) were consistent with deep vein thrombosis (DVT).Despite treatment, the patient's pain and swelling was exacerbating, which forced him to visit our hospital. Magnetic resonance imaging (MRI) revealed a diffused mass in his right thigh, while fine needle aspiration cytology (FNAC) yielded a diagnosis of B-cell lymphoid hyperplasia. The patient was then referred to a tertiary cancer treatment center for further management.

Anatomical Variations of the Left Subclavian Artery and Their Significance in Clinical Practice.

We study variations of the aortic arch (AA) and its first branches, the brachiocephalic, common carotid, and subclavian arteries. Specifically, we describe anatomical variations of the left subclavian artery (LSA) and their significance in clinical practice. Such variations are commonly associated with congenital anomalies of the right-sided AA (RAA) and/or great vessels. A systematic search of the PubMed online database for studies of LSA variations and RAA, published between 2000 and 2020, produced a total of 73 articles for our study (n = 258 cases). Three of the most common variants were aberrant LSA (32.9%), RAA with mirror-image branching (49.6%), and isolated LSA (17.4%). Although RAA and LSA variations are rare, they may give rise to symptoms during the first stages of life or adulthood and may require surgical repair. Patients can remain asymptomatic, but incidental findings on imaging studies may lead to surgical interventions in areas of the neck or thorax. In such cases, planning the surgical procedure can be challenging, and possible implications must be considered.

Three-Dimensional (3D) Printing in Orthopedics Education.

Three-dimensional (3D) printing is a newly established concept in orthopedics compared with other industries. Surgical applications of 3D printing and tissue engineering have been investigated since the early 2000s, almost two decades after Charles Hull had patented the first device currently in use for additive manufacturing, also known as rapid prototyping or more commonly 3D printing, and whose initial formal appellation was stereolithography (SLA). Despite technological progress, substantial principles have largely remained unaltered. Training directly on patients and on cadavers is considered the "gold standard" for learning and developing suitable surgical qualifications. However, restrictions concerning patient safety, ethical dilemmas, lack of availability, etc., have to be taken into account. Thus, 3D representations can be utilized as an educational tool both for patients to improve their understanding of their condition and also medical students, residents, and surgeons to comprehend complex anatomical structures and practice their surgical maneuvers to be prepared and more confident in theater.

Spontaneous Knee Hemarthrosis Due to Hypofibrinogenemia Following Tigecycline Treatment for Periprosthetic Joint Infection.

Tigecycline, a recently approved antibiotic, has a broad spectrum of antimicrobial activity. Its unique structure and properties make tigecycline a valuable option for the treatment of infections caused by many multidrug-resistant organisms. We present a case of an 82-year-old patient who developed a significant decrease of fibrinogen levels after the addition of tigecycline to his antibiotic regimen. The patient was treated for a periprosthetic knee joint infection caused by a multidrug-resistant extended-spectrum beta-lactamase-producing Escherichia coli. The reduction of fibrinogen levels, in this case, prompted severe spontaneous hemarthrosis. Tigecycline treatment was discontinued and coagulation disorders were normalized within the next few days. After several days, the joint had to be surgically debrided. Hypofibrinogenemia is a very scarcely reported side effect of tigecycline that can cause spontaneous hemarthrosis.

Bilateral Floating Knee Injury-Management of a Complex Injury.

Floating knee is a flail knee joint resulting from fractures of the shafts or adjacent metaphyses of the femur and ipsilateral tibia. Floating knee injuries may include a combination of diaphyseal, metaphyseal, and intra-articular fractures. Floating knee injuries are a group of complex injuries that require a careful assessment. This injury is generally caused by high-energy trauma with often extensive trauma to the soft tissues. There may also be life-threatening injuries to the head, chest, or abdomen and a high incidence of fat embolism. This complex injury has increased in proportion to population growth, number of motor vehicles on the road, and high-speed traffic. Although the precise incidence of a floating knee is not known, it is a relatively uncommon injury. Bilateral floating knee injuries are extremely rare, and there is only one case report in the literature with bilateral floating knee injuries. We present a case report of a 64-year-old lady who suffered a blunt abdominal injury (hemicolectomy and splenectomy) and bilateral floating knees during road traffic accident. We also offer guidance for the treatment of this complex injury, based on literature review.

The Use of Vacuum Closure-assisted Device in the Management of Compound Lower Limb Fractures with Massive Soft Tissue Damage.

The simultaneous exposure of tissue and bone poses specific management challenges. Patients with extended soft tissue damage and high-grade compound fractures present a demanding clinical challenge, requiring a complex approach and multiple orthopaedic, plastic, and vascular-reconstructive procedures. Management involves combinations of wound debridement and closure by secondary intention, use of vacuum-assisted closure (VAC) devices, and various reconstructive plastic surgery methods. We present three consecutive complicated cases, involving compound fractures of the lower limb with massive soft tissue damage (Gustilo-Anderson type IIIB) that were managed with debridement, application of external fixation and VAC device. The mean wound size was 24 cm in length and 12 cm in width. The aim of treatment was to cover the bone with soft tissue and achieve healing of the fracture without persistent infection. Wound healing was achieved in all three cases within 30-42 days (mean 34). In one case, the skin graft was applied on day 33. Utilizing this method as part of a multi-directional approach, the VAC system helps the patient recover faster. Moreover, it acts as a feasible and valuable method to treat compound fractures with massive soft-tissue defects. VAC can replace microsurgical soft-tissue transfer, reduce the risk of infection and allow salvaging the limb.

The Sensitivity of Magnetic Resonance Imaging and Ultrasonography in Detecting Rotator Cuff Tears.

Shoulder pain is a common cause of morbidity in the general population. Differential diagnosis may be difficult. Soft tissue shoulder disorders are the most common causes of shoulder pain. Noninvasive imaging techniques can reveal rotator cuff (RC) pathologies. These include ultrasonography (US) and MRI. Minimally invasive techniques such as magnetic resonance arthrography (MRA) can also be recruited when required. We conducted a retrospective study of 61 consecutive patients with shoulder pain, who had undergone preoperative imaging in the form of US or MRI and subsequently proceeded to arthroscopic surgery. Nineteen patients had a US and 42 had an MRI preoperative imaging evaluation. This evaluation was compared to the operative findings. The US sensitivity was 87%, while specificity was 63%. The MRI accuracy rose to a sensitivity of 95% when specificity was 72%. The positive predictive value (PPV) was 64% for US and 76% for MRI. The negative predictive value (NPV) was 87% for US and 94% for MRI. The overall accuracy of the ultrasound was 73% and of the MRI 83%.

Multifocal Οsteomyelitis Localization after Pyomyositis in Children: Importance of Timely Response.

Pyomyositis is a rare bacterial infection that used to prevail in tropical areas for the past century. Nowadays though, more and more cases are reported in high-temperature climate areas. Diagnosis is often delayed due to the variance in clinical presentation, the challenging nature of physical examination of a child, and lack of specific laboratory investigating tools. When the diagnosis is delayed, the outcome may be unpredictable. Multifocal localization through hematogenous or direct spread that may affect the skeletal bone tissue is common. Timely diagnosis and response is a race against septic shock. We present a case series of seven children diagnosed with pyomyositis due to Staphylococcus aureus. High or less clinical suspicion has obviously affected the final outcome since two patients who were not treated in time were subjected to a life-threatening hazard. Five patients who were diagnosed and treated within the first three days after initiation of their symptoms had a predictable and good outcome without complications.

Pathological Hip Fractures in Children and Adolescents Due to Benign Tumor or Tumor-Like Lesions.

Hip fractures are uncommon in childhood and adolescence. A high-energy injury is the most common cause. Low-energy trauma may result in a pathological hip fracture or stress fracture of the femoral neck, on the grounds of a preexisting skeletal disease, a tumor, or a tumor-like lesion. Surgical or conservative treatment may be provided based on underlying disease and/or age, Delbet and/or Colona classification, and displacement of the fracture. We present a case series of 13 children with pathological hip fracture. Mean age of patients was 7 years, and average follow-up was 3 years. There were types I and II, 3 type III, and 10 type IV fractures according to Delbet/Colona classification. Patients were treated conservatively, by open reduction and internal fixation or by minimally invasive surgery. In 11 children (84.5%), the outcome was satisfactory; one child (7.75%) presented with nonunion and refracture after minimally invasive surgery, and another (7.75%) presented with refracture after conservative treatment. Both patients were treated with open reduction and internal fixation. Pathological hip fractures are rare in children and should be treated properly. Surgical treatment with open reduction, internal fixation, and bone grafting is preferred in displaced fractures. In nondisplaced fractures, the choice between conservative and surgical treatment should be based on Delbet/Colona classification and patient profile.

Patella Height in Different Ethnic Populations: An Observational Multicenter Study.

Patella height appears to have a crucial role in knee biomechanics. Patellar malalignment and maltracking are therefore believed to be associated with development and progression of patellofemoral pain and disease. Published data are scant regarding the effect of everyday tasks on patella height and patellofemoral disease. We included 150 subjects in a retrospective observational study. Group A had 75 subjects (24 male and 51 female, with a mean age of 58.5 yr), whose daily activities included squatting (the traditional Muslim praying position called Sujud). Group B had 75 subjects (42 male and 33 female, with a mean age of 47.6 yr), who were non-Muslim. Patella height was measured using Insall-Salvati (IS) and Blackburne-Peel (BP) ratios. The mean IS ratio was 0.86 (confidence interval [CI]: 0.7-1.02) for group A and 1.1 (CI: 0.96-1.23) for group B. The mean BP ratio was 0.66 (CI: 0.49-0.83) for group A and 0.89 (CI: 0.73-1.04) for group B. We found 26 subjects (34.7%) in group B to have patella alta, when measured by either ratio, compared to one subject (1.3%) in group A (p < 0.01) with patella alta. We found 61 subjects (81.3%) in group A to have patella baja, when measured by either ratio, compared to 21 subjects (28%) in group A (p < 0.01) with patella baja. In group A, the IS ratio was reduced in 29 subjects (38.7%), the BP ratio was reduced in 59 subjects (78.7%), and both were reduced in 27 subjects (36%). A similar pattern was noted for group B. Our results show that a significant increase in patella baja was associated with repeated squatting/kneeling, compared to the predominance of patella alta in the control group. On the basis of these findings, we hypothesize that biomechanical stresses associated with repeated hyperflexion of the knee asymmetrically affect the more flexible quadriceps muscle fibers greater than patella tendon fibers. Thus, repeated hyperflexion in everyday tasks leads to elongation of quadriceps fibers and patella baja.

An Unusual Presentation of a Massive Acromioclavicular Joint Ganglion Cyst Geyser Sign Secondary to Massive Rotator Cuff Tear and Cuff Arthropathy.

A Geyser sign is a rare manifestation of acromioclavicular joint (ACJ) ganglion cysts that are seen in patients with massive rotator cuff tears and arthritis of the ACJ. We present a case report of a 70-yr-old male who was presented to our hospital with a massive AC ganglion cyst measuring 7 × 8 cm with normal shoulder function tests. Imaging studies revealed a massive rotator cuff tear, advanced cuff arthropathy, degeneration of the ACJ, and a Geyser sign (seen with magnetic resonance imaging). The cyst was initially aspirated but recurred, so open debridement distal clavicle resection and ganglion cyst excision were performed. Eight months following debridement, the patient visited the outpatient department with cyst recurrence and limited shoulder movement. A reverse shoulder arthroplasty was performed with good clinical results.

Hypoglossal Nerve: Anatomy, Anatomical Variations Comorbidities and Clinical Significance.

We review the anatomical variations of the hypoglossal nerve and their surgical and clinical significance, and we report multiple diseases that affect function of the nerve leading to paresis, either unilateral or bilateral. The hypoglossal nerve is the 12th cranial nerve, and knowledge of the detailed anatomy and relationship with critical structures is of paramount importance in neurosurgery, head and neck surgery, and vascular surgery. Numerous studies have depicted conventional landmarks in the cervical part of the hypoglossal nerve, but their findings have not been consistent reliable. We analyze and review these critical landmarks used to identify and preserve the hypoglossal nerve during surgery and to minimize iatrogenic complications in head and neck, neurosurgical, and vascular procedures. We performed an online database search during January and February 2019 to pinpoint the diseases that affect function of the nerve. According to this literature review, apart from iatrogenic injury during surgery, the most frequently observed cause of paresis is pressure due to the presence of tumours and head injury. Furthermore, motor neuron degenerative conditions, such as amyotrophic lateral sclerosis, multiple sclerosis or tooth infection and presence of an aberrant vessel in the hypoglossal canal can affect the function of the nerve.