The clinical and radiographic degenerative spondylolisthesis classification and its predictive value.

INTRODUCTION: The clinical and radiographic degenerative spondylolisthesis (CARDS) classification is a new classification that has been introduced for degenerative spondylolisthesis (DS). It has four categories. Our study aimed to analyse the functional and radiographic outcome following DS surgery based on the preoperative CARDS classification. METHODS: A retrospective study of the prospectively collected Australian Spine Registry database was performed. Data on demographics, patient reported outcome measures including the Oswestry Disability Index (ODI) and EQ-5D-3 L scores, and changes in radiographic measurements were analysed. Based on the preoperative findings all x-rays were classified applying the CARDS classification. RESULTS: Between 2018 and 2021 a total of 54-patients were identified as having had surgery for DS at L4/5. The mean age was 65.3 ± 11.3years and females were predominantly affected (61%). Most cases were of CARDS type C (46%), followed by type B (29%). CARDS type A and D were observed in 18% and 6% respectively. Preoperatively, the L4/5 lordosis was 19.8 ± 6.3° and lumbar lordosis 43.9 ± 12.8°. Postoperatively the L4/5 lordosis alignment changed significantly to 23.5 ± 8.8° (p < 0.05). Preoperatively, the CARDS classification was 34.8 ± 17.4 (type A), 40.5 ± 11.0 (type B), 43.8 ± 12.9 and 50.0 ± 14.4 for type D (Pearson-coefficient 0.284, p = 0.041). Postoperatively this changed to 22.7 ± 16.1, 28.7 ± 21.2, 12.5 ± 13.1, and 6.5 ± 2.1 respectively. Similar improvements were observed for the EQ-5D-3 L. CONCLUSION: This study shows that the CARDS classification correlates with preoperative functional scores as well as helping to predict response to surgery. CARDS will likely assist in operative planning and prognostication. LEVEL OF EVIDENCE: III, therapeutic and prognostic study.

Percutaneous elevation of radial head fractures without fixation - a promising technique.

The aim of the study is to describe the surgical technique and to report the outcomes of triceps reflecting anconeus pedicle (TRAP) approach for intercondylar fractures of the humerus. Twenty two patients with intercondylar fractures of the humerus were operated on by open reduction via the TRAP approach and internal fixation with dual precontoured locking plates. Data were collected on union time, postoperative complications, range of motion (ROM), triceps power, and objective clinical measurement. All fractures were united with a mean union time of 16.5 weeks (range 12-22). All patients had good-to-excellent Mayo Elbow Performance (MEP) score results with a mean ROM of 118.2 degrees (range 90-135). Triceps power was grade 5 in 16 patients and grade 4 in 6. There were 3 transient ulnar nerve palsy and 1 heterotopic ossification. TRAP approach is safe and effective in terms of utility for articular reduction, restoration of elbow motion, and triceps function for intercondylar fractures of the humerus.

Modular uncemented revision total hip arthroplasty in young versus elderly patients: a good alternative?

For revision hip arthroplasty, both cemented and cementless techniques have been described for implantation of modular and non-modular implants. Although many articles have been published on non-modular prosthesis, there is a dearth of data on cementless, modular revision arthroplasty in young patients. This study aims to analyze the complication rate of modular tapered stems in young patients below 65 years of age as compared to elderly patients older than 85 years old, in order to predict the complication rate. A retrospective study was performed using a major revision hip arthroplasty center database. Inclusion criteria consisted of patients undergoing modular, cementless revision total hip arthroplasties. Data on demographics, functional outcome, intraoperative, early and medium term complications were assessed. In total, 42 patients met inclusion criteria (<65 years old: 25 patients; >85 years old: 17 patients). For the <65 years old cohort, the mean age and follow-up time was 55.4 ± 9.3 years old and 13.3 ± 13.2 months, respectively. For the >85 years old cohort, the mean age and follow-up time was 87.6 ± 2.1 years old and 4.3±8.8 years, respectively. For intraoperative and short-term complications, no significant differences were observed. Medium term complication is noted in 23.8% (n=10/42) overall, preferentially affecting the elderly group at 41.2% (only 12.0% in the younger cohort; p=0.029). To our knowledge, this study is the first to investigate the complication rate and implant survival for modular revision hip arthroplasty based on age group. It shows that the complication rate is significantly lower in young patients and age should be a consideration in surgical decision making.

Anterior communicating artery aneurysm rupture and functional outcome in short-term: clipping versus coiling.

Our research aims to assess the change in the grade of responsiveness using the Hunt and Hess score as well as the modified ranking scale in patients suffering from anterior communicating artery rupture. We retrospectively analyzed data from 11-patients who suffered from an anterior communicating artery aneurysm rupture that caused a subarachnoid hemorrhage. Severity was assessed using the Hunt and Hess scale grade and modified ranking scale. Anterior communicating artery rupture caused a subarachnoid hemorrhage in 40.81% of all aneurysm ruptures that took place at the Circle of Willis. Unfortunately, 4-patients deceased (3.4%) at a median age of 52-years (range 34-75-years), three of which deceased after coiling and one after clipping. In 71-patients (61.2%) endovascular coiling was performed - 33-males and 38-females - and in the remaining 45-cases, (38.8%) clipping was indicated - 24-males and 21-females. Overall, the pre-interventional median Hunt and Hess scale was 2, which remained after the intervention. When relating the outcome score to the intervention performed, we found that the Hunt and Hess scale score was 3 before coiling and 2 before clipping, whereas afterward, there was a slight increase to 2 and 2, respectively. The modified ranking scale was 2 after clipping, respectively, coiling (P = 0.218). No significant differences were observed between the different groups. Our results show that clipping is as effective as coiling in terms of the Hunt and Hess scale and the rate of mortality in the short-term.

Blood Loss Following Open Posterior Spinal Fusion in Fractures: Cannulated vs. Solid Pedicle Screws.

We aim to delineate whether there is increased blood loss with the use of cannulated pedicle screws compared to solid pedicle screws in patients undergoing posterior spinal fusion. A single-centre retrospective case-control study was undertaken on patients undergoing PSF for spinal fractures. Cannulated screw fixation was compared with solid screw fixation. Intraoperative blood loss was estimated using pre and postoperative haemoglobin levels, recorded estimated blood loss and cell saver reports. Anticoagulation, blood product administration, operative time and number of levels fused were assessed. A total of 64 cases, 32 in each cohort, were included in the analysis. Overall mean haemoglobin reduction from pre- to post-operative was 2.82 ± 1.85 g/L per screw inserted in the cannulated group, compared to a haemoglobin decrease of 2.81 ± 1.521 g/L per screw inserted in the solid screw group (p = 0.971). Total estimated intraoperative blood loss was 616.3 + 355.4 mL in the cannulated group, compared to 713.6 + 473.5 mL in the solid screw group (p = 0.456). Patients with preoperative thrombocytopenia had a transfusion rate of 0.5 ± 0.71 units/patient compared to 0.04 ± 0.19 units/patient in patients with normal platelet levels (p < 0.005). The differences in blood loss observed between cannulated and solid pedicle screws are non-significant overall. The largest predictor for need of transfusion was pre-operative thrombocytopenia, regardless of the type of screw used.

Clinical Outcome after Medial Open-Wedge High Tibial Osteotomy: Comparison of Two Angular Stable Locking Plates-TomoFix™ versus LOQTEQ® HTO Plate.

This study evaluated bony healing and clinical results after medial open-wedge HTO to compare the outcome of the LOQTEQ® HTO plate and the TomoFix™ internal plate fixator. A prospective, non-randomised, comparative study was undertaken. The same surgical technique for the medial open-wedge HTO was used in two treatment groups. In Group 1, the TomoFix™ implant was used for osteosynthesis, and, in Group 2, the LOQTEQ® HTO plate was used. All patients were examined before surgery (T0) and then at 12 months (T1) and at 24 months (T2) postoperatively. The primary outcome measure was the KOOS pain subscore. The secondary outcome criteria were other KOOS subscales, the Tegner score, radiological healing (RUST), and incision length. The KOOS pain subscale and the other KOOS subscores increased significantly in both groups from T0 to T1 and T2 without a significant group difference at each timepoint. The activity measured with the Tegner scale increased significantly from T0 to T2 without a significant group difference. No radiological signs of implant failure were observed in any case at the one-year X-ray, and no patient fulfilled the criteria for non-union. There was no significant difference in the frequency of adverse effects between the two treatment groups. The length of the incision was significantly shorter in the LOQTEQ® HTO group than in the TomoFix™ group. The results of this study show that patient-related outcome scores (KOOS, Tegner) increased after medial open-wedge HTO. There was no difference in clinical outcome or radiological healing between the treatment groups. Both plates are suitable for the osteosynthesis of open-wedge HTO.

A Review of Functional Outcomes after the App-Based Rehabilitation of Patients with TKA and THA.

Following the outbreak of SARS-CoV-2, several elective surgeries were cancelled, and rehabilitation units were closed. This has led to difficulties for patients seeking access to rehabilitation in order to achieve the best possible outcome. New applications with or without sensors were developed to address this need, but the outcome has not been examined in detail yet. The aim of this study was to perform a systematic literature review on smart phone applications for patients suffering from hip and knee osteoarthritis after arthroplasty. The MEDLINE/PubMed and Google databases were queried using the search term "[APP] AND [ORTHOPEDIC]" according to PRISMA guidelines. All prospective studies investigating rehabilitation applications reporting the functional outcome in hip and knee osteoarthritis after arthroplasty were included. The initial search yielded 420 entries, but only 9 publications met the inclusion criteria, accounting for 1067 patients. In total, 518 patients were in the intervention group, and 549 patients were in the control group. The average follow-up was 9.5 ± 8.1 months (range: 3 to 23.4 months). Overall, significantly lower A-VAS values were observed for the interventional group in the short term (p = 0.002). There were no other significant differences observed between the two groups. Smart phone applications provide an alternative to in-person sessions that may improve access for patients after total joint arthroplasty. Our study found there are significant improvements in the short term by using this approach. In combination with a blue-tooth-enabled sensor for isometric exercises, patients can even receive real-time feedback after total knee arthroplasty.

Fibula Fracture: Plate versus Nail Fixation.

Backgroud: Intramedullary fixation has only uncommonly been used in the fibula although it may confer some advantages. Our goal was to investigate a single surgeon's learning curve with initial usage of an intramedullary device for fibular fixation based on surgical time and quality of reduction. Methods: Prior to initiation of this study, an experienced ankle fracture surgeon performed fibular nail fixation in a sawbones and a cadaver setting. Between February and August 2018, all patients who suffered from a distal fibula fracture underwent fibula fixation (n = 20) using the Fibulock (Arthrex). Patients were retrospectively investigated and compared with a control of fibular plate fixation. The tourniquet time, time of anesthesia, and surgery time were recorded as well as the quality of reduction. Results: In the 20 cases, the mean tourniquet time was 68.9 ± 23.2 minutes for nail fixation, while in the fibular plate fixation group, the mean time was 75.8 ± 23.9 minutes (p = 0.37). Two patients had slight malreductions (first and third cases): one was corrected with a lag screw outside the nail, the other was an elderly patient with significant blistering in whom an entirely percutaneous reduction was performed. Conclusions: Intramedullary fixation for fibular fractures does not appear to have a significant learning curve for an experienced ankle fracture surgeon.

Isolated Femoral Shaft Fracture in Wakeboarding and Review of the Literature.

INTRODUCTION: Wakeboarding is an extreme sport that has shown increasing popularity in recent years, with an estimated 2.9 million participants in 2017. Due to this trend, injuries related to this sport are likely to become more common. Isolated femoral shaft are rare; however, they occur much more frequently in youth as a result of high velocity events, such as dashboard-related injuries. Few studies have addressed injuries related to wakeboarding, and of those that have, most have reported on muscle injuries, ligament ruptures, and sprains. Due to the dearth in literature, we want to present two cases of isolated noncontact femoral shaft fractures that resulted from wakeboarding. Case Presentation. Two 28-year-old, otherwise healthy, wakeboarders-patient A, male, and patient B, female-presented to our Department of Orthopaedics and Sports Medicine with isolated femoral shaft fractures. Both were admitted due to wakeboard-related noncontact injuries, where patient A fell while performing a sit-down start during cable wakeboarding and patient B after attempting a wake-jump. Both patients were being pulled by motorboats at roughly 40 km/h. After clinical examination and radiography, left spiral (AO classification: 32-A1.2) (patient A) and right-sided bending, wedge (AO classification 32-B2.2) (patient B) isolated femoral shaft fractures were diagnosed. No concomitant injuries were reported. For treatment, long reamed locked nails were applied, while the patients were under spinal anaesthesia. Physiotherapy was prescribed postoperatively. Patient A returned to wakeboarding 155 days after the surgery, and patient B returned after approximately half a year. CONCLUSION: This case series shows that even in noncontact sports such as wakeboarding, high-energy forces applied to the femur can cause isolated femoral shaft fractures. Despite multiple reports in various sports of stress fractures of the femur, there are few publications of direct trauma.

Systematic Review of Diagnosis of Clinically Suspected Scaphoid Fractures.

Background Scaphoid fracture accounts for approximately 15% of acute wrist fractures. Clinical examination and plain X-rays are commonly used to diagnose the fracture, but this approach may miss up to 16% of fractures in the absence of clear-cut lucent lines on plain radiographs. As such, additional imaging may be required. It is not clear which imaging modality is the best. The goal of this study is to summarize the current literature on scaphoid fractures to evaluate the sensitivity, specificity, and accuracy of four different imaging modalities. Case Description A systematic-review and meta-analysis was performed. The search term "scaphoid fracture" was used and all prospective articles investigating magnetic resonance imaging (MRI), computed tomography (CT), bone scintigraphy, and ultrasound were included. In total, 2,808 abstracts were reviewed. Of these, 42 articles investigating 51 different diagnostic tools in 2,507 patients were included. Literature Review The mean age was 34.1 ± 5.7 years, and the overall incidence of scaphoid fractures missed on X-ray and diagnosed on advanced imaging was 21.8%. MRI had the highest sensitivity and specificity for diagnosing scaphoid fractures, which were 94.2 and 97.7%, respectively, followed by CT scan with a sensitivity and specificity at 81.5 and 96.0%, respectively. The sensitivity and specificity of ultrasound were 81.5 and 77.4%, respectively. Significant differences between MRI, bone scintigraphy, CT, and ultrasound were identified. Clinical Relevance MRI has higher sensitivity and specificity than CT scan, bone scintigraphy, or ultrasound. Level of Evidence This is a Level II systematic review.

Fibular Plate Fixation and Correlated Short-term Complications.

Background. The most common method of surgical stabilization of fibular fractures is plate osteosynthesis. Despite its ubiquity, there is a dearth of large series reporting implant-related outcomes and complications. The purpose of this study was to report on short-term complications and hardware removal after plate fixation of distal fibula fractures. Methods. A retrospective chart analysis and review of radiographic images was performed of 461 ankle fractures between 2011 and 2017. In 404 cases, a fibular fracture was treated surgically; 94.1% underwent tubular and 5.9% locking plate fixation. The primary outcome was radiographic union, with a mean follow-up of 11.6 months. Minor, intermediate, and major complications were recorded as well as the rate of hardware removal. Results. The union-rate with plate fixation was 99.5% (402/404). The overall complication rate was 19.3% (n = 78/404). Of these complications, 79.5% (62/78) were considered minor. These complications included erythema, heterotopic ossification, neurapraxia, delayed union, and deep-vein thrombosis; 20.5% (16/78) of the complications were considered intermediate (9/78, 11.5%) or major (7/78, 9.0%). Intermediate and major complications included deep infection, nonunion/malunion, and osteomyelitis. Subsequent surgery was needed in 7 cases (1.7%, 7/404). In another 93 patients, hardware-related symptoms were identified: 23 (5.7%) underwent syndesmosis screw removal and 54 (13.4%) hardware removal. No correlation to the fixation technique was identified. Conclusion. This study shows a relatively low rate of major complications and a high union rate of 99.5% for fibular plate osteosynthesis in a large cohort. Any other treatment, including other fixation techniques, will need to show an equivalent or better complication and reoperation profile.Level of Evidence: Level III: Retrospective, comparative study.

Epidemiology and injury patterns of aerial sports in Switzerland.

BACKGROUND: Airborne sports have become more popular in recent years. The number of accidents has increased linearly as athletes take increasingly greater risks to experience the adventurous spirit of this kind of sports. AIM: To investigate the variety of injuries in airborne sport accidents, as well as which acute treatment these patients receive, both before and after admission to a level-one-trauma center. METHODS: We performed a retrospective chart analysis at a major level-one-trauma center in Switzerland for 235-patients who were admitted following airborne sports injuries between 2010 and 2017. Patients' demographic data, injury patterns, emergency primary care procedures and intra-hospital care were recorded. RESULTS: Overall, 718-injuries in 235-patients were identified; the spine was the most commonly affected region with 46.5% of injuries (n = 334/718) in 143-patients. In 69-patients (15.5%), the (non-spine) thorax was affected, followed by the lower and upper extremity, pelvis, head/face and abdominal injuries. Eleven-patients had to be intubated at the trauma site. Three patients were resuscitated after onset of pulseless-electrical-activity. Two-patients died in the resuscitation room. In 116-cases, surgery was indicated including 55-emergency surgeries. Another 19 patients (8.1%) were transferred to the intensive care unit. CONCLUSION: Paragliders are most commonly affected, although the highest injury severities were identified for Building, Antenna, Span and Earth-jumping athletes. First responders, treating physicians and pilots should be aware of the risk for potentially serious and life-threatening injury with an in-hospital mortality of 0.9%.

Exertional rhabdomyolysis and causes of elevation of creatine kinase.

Background: Rhabdomyolysis is a potentially fatal condition that can be triggered by a variety of inciting events, including excessive muscular exertion.The purpose of this study was to investigate the causes of creatine kinase elevation (CK≥1000U/L) to determine what percentage result from exRML, the etiology, and kinetics of CK levels, as well as the complications of exRML and comorbidities that may predispose an individual to this condition.Methods: We performed a cross-sectional analysis of the emergency department database for patients with CK≥1000U/L between 2012 and 2017. In total, there were 1957 cases of rhabdomyolysis diagnosed based on laboratory data and documentation. Trauma was the most common cause for rhabdomyolysis (n = 726/1957; 37.1%, respectively).Results: ExRML was identified in 2.1% (n = 42/1957) of the total cases. Patients with ExRML were significantly younger (30.1 ± 10.6 years) with a significantly higher maximal level of CK compared to the non-exertional causes of rhabdomyolysis, (CK = 16,884.4 ± 41,645.6U/L; both p < 0.005). The far majority of cases were sport or exercise related (n = 35/42; 83.3%), with strength training at the gym making up the largest group of athletes (n = 16/42; 38.1%). The main complication amongst the ExRML group was acute kidney insufficiency, which was observed in 42.9% of patients. The CK levels of the patients in the ExRML cohort steadily decreased after initiation of aggressive hydration.Conclusion: ExRML may be more prevalent than the current literature predicts, which is important to recognize as it has the potential to cause kidney failure, irregular heart rhythm, and death. Therefore, physicians and active individuals should be sensitized to the signs and symptoms that may lead to earlier recognition and proper treatment in exercising individuals.

Subtraction hemiarthoplasty in basal joint arthritis: A case report.

BACKGROUND: Basal joint arthritis is a common disease which is especially present in post-menopausal women. A variety of procedures have been described once conservative treatment has failed. The purpose of our study is to present a novel surgical technique based on a clinical case with three-year follow-up which is highly effective, even after failure of previous procedures. CASE SUMMARY: We present a case of a 39 year-old-woman who suffered from recurring, persistent, sharp left thumb pain for several years After two operative procedures, she presented again with intolerable, sharp pain over the trapeziometacarpal joint, and wished to proceed with a pain relieving procedure or arthroplasty. Intraoperatively, the articular surfaces appeared well, without any bare areas of bone or eburnation, resulting in the decision to perform a "subtraction hemiarthroplasty". A shortening osteotomy of the os trapezium was performed by removing a slice of 8-9 mm bone, without damaging the joint cartilages. The osteotomy was stabilized using two screws, the ligament and capsular tissue was suture imbricated, and a cut down on the translation and a dorsal radial ligament reconstruction were performed. Three years after the final procedure, a long-term follow-up demonstrates excellent results, pain free with full range-of-motion. CONCLUSION: Subtraction hemiarthroplasty with ligament tightening imbrication and reconstruction of the radial ligament led to excellent results in motion and pain.

Biomechanics of posterior shoulder instability - current knowledge and literature review.

Posterior instability of the shoulder is a rare condition and represents about 10% of shoulder instability. It has become more frequently recognized in the last year, even though it is more difficult to diagnose than anterior shoulder instability. As this form of shoulder pathology is somewhat rare, biomechanical knowledge is limited. The purpose of our study was to perform an extensive literature search, including PubMed and Medline, and to give an overview of the current knowledge on the biomechanics of posterior shoulder instability. The PubMed/Medline databases were utilized, and all articles related to posterior shoulder instability and biomechanics were included to form a comprehensive compilation of current knowledge. A total of 93 articles were deemed relevant according to our inclusion and exclusion criteria. As expected with any newly acknowledged pathology, biomechanical studies on posterior shoulder instability remain limited in the literature. Current biomechanical models are performed in a static manner, which limits their translation for explaining a dynamic pathology. Newer models should incorporate dynamic stabilization of both the rotator cuff and scapulothoracic joint. There is a current lack of knowledge with regards to the pathomechanism of posterior shoulder instability, with no consensus on appropriate treatment regimens. Further investigation is therefore required at both basic science and clinical levels.