Subtrochanteric Shortening Osteotomy Provides Superior Function to Trochanter Slide Osteotomy in THA for Patients With Unilateral Crowe Type IV Dysplasia at a Minimum of 3 Years.

BACKGROUND: Performing THA in patients with high-riding developmental dysplasia of the hip (DDH) is associated with serious complications and technical challenges. Various methods of shortening osteotomy are available to facilitate femoral head reduction during THA in patients with high-riding hips; subtrochanteric shortening osteotomy and trochanteric slide osteotomy plus proximal shortening are the most common techniques. However, which approach is superior remains a topic of controversy. QUESTIONS/PURPOSES: (1) Is there any difference in clinical outcomes (defined as the Harris Hip Score [HHS] and residual limb length discrepancy) at a minimum of 3 years between subtrochanteric shortening osteotomy and trochanteric slide osteotomy in patients with Crowe Type IV DDH who underwent THA? (2) Is there any difference in the risk or type of complications between the two approaches? METHODS: We performed a retrospective, comparative study of two groups (subtrochanteric shortening osteotomy versus trochanteric slide osteotomy) matched for sex and preoperative HHS at a minimum of 3 years of follow-up. Between 2010 and 2018, we performed 67 THAs in patients with unilateral Crowe Type IV DDH. During that time, we generally used a trochanteric slide osteotomy for THA in all patients with Crowe Type IV hips and performed subtrochanteric shortening osteotomy when a conical stem was not available. A total of 42% (28) had THA with subtrochanteric shortening osteotomy, and 58% (39) had THA with trochanteric slide osteotomy. Of those, 89% (25) and 74% (29), respectively, were accounted for with complete datasets for possible matching at a minimum of 3 years of follow-up. Patients were matched for gender and preoperative HSS (within 10 points), leaving 22 patients in each group (79% of the subtrochanteric shortening osteotomy group and 56% of the trochanteric slide osteotomy group) for evaluation and analysis. Age (42 versus 46 years), gender (female: 73% versus 73%), preoperative HSS (40 versus 40), and preoperative leg length discrepancy (5.9 versus 5.3 cm) were comparable between the two groups (p > 0.05). The trochanteric slide osteotomy group exclusively received Cone Wagner (Zimmer) implants (100%), while Corail (DePuy Synthes) implants (77%) were the most commonly used in the subtrochanteric shortening osteotomy group. HHS at a minimum of 3 years as well as the presence or absence of a limp and Trendelenburg sign, functional leg length discrepancy, nonunion, nerve palsy, and other surgical complications were recorded and compared between the groups based on data drawn from a longitudinally maintained institutional database. RESULTS: At a mean follow-up of 73 months, improvement in HHS was greater in the subtrochanteric shortening osteotomy group than in the trochanteric slide osteotomy group (48 ± 4 points versus 36 ± 11 points, mean difference 12 points [95% CI 7 to 17 points]; p < 0.001). Although the preoperative leg length discrepancy was similar between the groups, there was a greater postoperative improvement in the subtrochanteric shortening osteotomy group (44 ± 8 mm and 38 ± 8 mm in the subtrochanteric shortening osteotomy and trochanteric slide osteotomy groups, respectively; p = 0.02). The risk of nonunion was higher with a trochanteric slide osteotomy than with a subtrochanteric shortening osteotomy (23% [5 of 22] versus 0% [0 of 22]; p = 0.048). Other complications, including intraoperative periprosthetic fractures, nerve palsy, heterotopic ossification, revision surgery, and dislocation, did not differ between the groups. CONCLUSION: In patients with Crowe Type IV hips undergoing THA, surgeons might consider subtrochanteric shortening osteotomy rather than trochanteric slide osteotomy to minimize the risk of nonunion and achieve superior hip function. Better correction of leg length discrepancy may also be possible with subtrochanteric shortening osteotomy. The long-term survivorship of hips after these two techniques, as well as the influence of the specific anatomy of the proximal femur on the choice of technique, remain to be explored in future studies. LEVEL OF EVIDENCE: Level III, therapeutic study.

Acetabular and sacral insufficiency fractures in a patient with a long-term history of Alendronate consumption; a case report.

BACKGROUND: Long-term Bisphosphonate consumption has been reported to be associated with the incidence of atypical or insufficiency fracture, particularly in the proximal femur. We observed a case of acetabular and sacral insufficiency fractures in a patient with a long-term history of Alendronate consumption. CASE PRESENTATION: A 62-year-old woman was admitted with a complaint of pain in right lower limb following low-energy trauma. The patient had a history of Alendronate consumption for more than 10 years. The bone scan revealed increased radiotracer uptake in the right side of the pelvic, proximal right femur, and sacroiliac joint. The radiographs showed type 1 sacrum fracture, acetabulum fracture with femur head protrusion into the pelvis, quadrilateral surface fracture, fracture of the right anterior column, and right superior and inferior pubic fracture. The patient was treated with total hip arthroplasty. CONCLUSION: This case highlights the concerns regarding long-term bisphosphonate therapy and its potential complications.

Challenges in Managing Vancomycin Flushing Syndrome Following Vancomycin-Loaded Bone Cement for Periprosthetic Joint Infection: A Case Report.

Periprosthetic joint infection (PJI) is a critical complication following arthroplasties, often treated with a two-stage revision using antibiotic-loaded bone cement spacers. Although these spacers can effectively manage infections, they occasionally cause severe adverse reactions. We reported the case of a 68-year-old female who developed vancomycin flushing syndrome (VFS), previously known as the red man syndrome, following the insertion of a vancomycin-loaded bone cement spacer during the first-stage revision surgery for PJI after undergoing total knee arthroplasty. Six hours postoperatively, she developed pruritus, diffuse rash, tachycardia, and hypotension. VFS was diagnosed based on clinical presentation after excluding other potential causes. She was treated with intravenous epinephrine, antihistamines, steroids, and fluid resuscitation without requiring spacer removal. The patient recovered uneventfully, underwent second-stage reimplantation after 6 weeks, and remained asymptomatic at 2-year follow-up. This highlights the importance of anticipating and managing this potentially severe reaction through a multidisciplinary approach, considering the risks and benefits of retaining versus removing antibiotic-loaded bone-cement spacers.

Demographic and Injury Characteristics as Potential Risk Factors for Anterior Cruciate Ligament Injuries: A Multicentric Cross-Sectional Study.

Background: Anterior cruciate ligament (ACL) injuries are prevalent and can have debilitating consequences, with various factors potentially influencing their occurrence. This multicentric study aimed to comprehensively analyze the epidemiological characteristics of ACL injuries. We hypothesized that specific patient characteristics, such as age, sex, body mass index (BMI), and sports involvement, would be associated with distinct injury patterns and risk profiles. Methods: This cross-sectional study analyzed the medical records of 712 patients aged 15-60 diagnosed with ACL rupture. Data on demographics, injury mechanisms, associated injuries, graft type, and sports involvement were collected. Results: The majority of patients were male (93.1%), aged 15-30 years (80.2%), and overweight (66.7%). Autografts were the predominant graft choice (96.07%). Associated injuries were present in 79.5% of cases, with medial meniscus ruptures being the most common (37.36%). Sports-related (49.3%) and non-sports-related (50.7%) injuries were nearly equal, with non-contact injuries more prevalent (71.1%). In the sports-related subgroup, associated injuries emerged as a significant risk factor for ACL rupture (p = 0.014, OR = 1.596, 95% CI: 1.101-2.314), whereas non-contact mechanisms showed borderline significance (OR = 0.75, p = 0.09). Moreover, younger athletes were more susceptible to sports-related injuries (p = 0.024), with football being the primary sport involved. Conclusions: This study identified a high prevalence of concomitant injuries with ACL injury, which increased the risk of ACL injury, particularly in sports-related cases. Age-related differences in injury patterns highlight the need for age-appropriate preventive measures, especially for younger athletes participating in high-risk sports. This underscores the need for comprehensive injury assessment, targeted prevention strategies, and optimized clinical management approaches tailored to different populations' specific characteristics and risks.

Predictors and Prevalence of Persistent Pain after Total Knee Arthroplasty in One-Year Follow-up.

Background: Total knee arthroplasty (TKA) is one of the most common surgeries performed to reduce pain and disability in knee arthritis. Comprehension of the etiology and prevalence of persistent postoperative knee pain can help reduce this pain and identify the predictive factors leading to it. This study aimed to investigate the predictive factors and the prevalence of persistent pain after total knee arthroplasty in one-year follow-up. Materials and Methods: This was a prospective cohort study. Demographic data including age, sex, body mass index (BMI), hospital anxiety and depression scale (HADS), and comorbidities were collected. In 242 patients, preoperative and postoperative Western Ontario and McMaster Universities Arthritis Index (WOMAC) scores were measured before and immediately after surgery and in 3-, 6-, and 12-month intervals during follow-up. Loosening of the prosthesis was also investigated by radiographic imaging in every postoperative visit. Result: WOMAC pain decreased from a mean (standard deviation) of 49 before surgery to 18 at 6 months and 13 at 12 months. Despite this, the prevalence of moderate-to-severe persistent postoperative pain (PPP) was 13.22% (n = 32) and 9.09% (n = 22) at 6 and 12 months lower preoperative WOMAC (odd's ratio:2.8), loosening of the prosthesis (odd's ratio:1.9), higher HADS (odd's ratio:2.1) were main predictors for PPP in TKA patients as in rheumatoid arthritis (odd's ratio:1.2). Conclusion: Loosening of the prosthesis and higher preoperative WOMAC scores are key factors in persistent post-TKA pain. Depression and anxiety are more popular among patients with more pain after TKA. RA is more prevalent in patients with PPP after TKA.

Pie-Crusting Technique of Medial Collateral Ligament for Total Knee Arthroplasty in Varus Deformity: A Systematic Review.

Background: We aimed to better understand the outcomes/complications of pie-crusting technique using blade knife during total knee arthroplasty (TKA) in patients with knee genu varum deformity. Materials and Methods: A systematic search was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. English and Persian language articles were considered on the use of pie-crusting technique during TKA in patients with knee genu varum/varus deformity using related keywords and Medical Subject Headings terms with reported postoperative complications and outcomes. Results: Primary search resulted in 81 studies of them 9 included in our study (ages ranged: 19 years to 62 years). No perioperative complications and/or any significant differences between pie-crusting and control group were observed. Except for two studies that found no significant positive effect for the use of pie-crusting, other studies found pie-crusting a useful and promising technique. Four studies found significant improvement in pie-crusting group compared to control in terms of functional Knee Society Score (KSS), range of motion (ROM), medial gap, and the knee-specific KKS. Three records found no significant differences in terms of functional KSS, ROM; however, they reported fewer use of constrained inserts or a reasonable correction of femoral tibial angle. No serious complications were reported. Conclusions: Due to the inconsistency of the results on the efficiency and outcomes of pie-crusting, we cannot make a firm conclusion and more high-quality studies are needed in this regard. However, this method can be considered as a safe method which depends on the skill of surgeon.

Cross-Cultural Adaptation and Validation of the Persian Version of the Harris Hip Score.

Background: The Persian language, also known as Farsi, is a pluricentric language spoken in Iran, Afghanistan, and Tajikistan by about 140 million people. This study aims to translate the Harris hip score (HHS) into Persian with cross-cultural adaptation and to evaluate its validity and reliability. Methods: One hundred fifty-six total hip arthroplasty patients completed the Persian version of the HHS, Western Ontario and McMaster Universities Osteoarthritis Index, Forgotten Joint Score, and visual analog scale (VAS) for pain and satisfaction postoperatively. Using Cronbach's alpha (α) coefficient, internal consistency was evaluated. Correlations (Spearman's Rho) were used to assess validity. A test-retest reliability assessment of the Persian HHS was conducted (n = 47) using the intraclass correlation coefficient. Content validity was evaluated using the floor and ceiling effects of the HHS. Results: The final translation of the Persian HHS was approved to be used. The preoperative and postoperative Cronbach's alpha were 0.71 and 0.70, respectively, and showed acceptable internal consistency. The intraclass correlation coefficient was excellent (0.869, P < .001). Insignificant ceiling effects (13.5%) and no floor effects (0) were observed. The HHS score was significantly and strongly correlated with Western Ontario and McMaster Universities Osteoarthritis Index (r = 0.696, P < .001), VAS pain (r = 0.654, P < .001), VAS satisfaction (r = 0.634, P < .001), and Forgotten Joint Score (r = 0.648, P < .001). Conclusions: The Persian HHS demonstrated excellent reliability and validity properties. Accordingly, Persian HHS may be a helpful tool for assessing patients undergoing total hip arthroplasty.

Simultaneous femoral head reduction osteotomy (FHRO) combined with periacetabular osteotomy (PAO) for the treatment of severe femoral head asphericity in Perthes disease.

BACKGROUND: The purpose of this study is to describe the midterm clinical and radiologic outcomes of concurrent femoral head reduction osteotomy (FHRO) and periacetabular osteotomy (PAO) in Legg-Calvé-Perthes disease (LCPD) patients with major aspherical femoral head deformities. METHODS: The study included four Perthes patients in Stage IV of Waldenstrom's classification with a mean age of 10.5 and severe femoral head asphericity. They were treated with a combination of FHRO + PAO and followed for at least 2 years. An evaluation of the radiological outcome of the surgery was carried out based on the lateral center to edge angle (LCEA), the anterior center to edge angle (ACEA), the Tönnis angle, the head sphericity index, the Stulberg classification, the extrusion index, and Shenton's line integrity. An evaluation of the clinical outcome was made by evaluating hip range of motion (ROM), Harris hip score (HHS), and Merle d'Aubigne´-Postel score. RESULTS: All radiographic measures improved; three patients were classified as Stulberg class II and one as class III. The LCEA, ACEA, and Tönnis angle improved by 29° (from 3° to 32°), 16° (from 14° to 30°), and - 10° (from 18° to 8°), respectively. The mean femoral head sphericity index and extrusion index improved by 12% (from 83 to 95%) and - 33% (from 40 to 7%). No disruption was observed in the postoperative Shenton's line. According to HHS, all patients have shown excellent hip function, which improved by 27 points (from 69 to 96). Moreover, the hip ROM was increased from 222° to 267°. The follow-up period did not reveal any serious postoperative complications, such as osteonecrosis or conversion to arthroplasty. CONCLUSIONS: Combined FHRO with PAO may improve the hip joint's morphology and function in patients with residual femoral head deformity and acetabular dysplasia due to LCPD. Despite being considered a complex and demanding hip surgery, these results suggest a more widespread implication of the salvage procedure.

Comparison of hook plate versus T-plate in the treatment of Neer type II distal clavicle fractures: a prospective matched comparative cohort study.

BACKGROUND: This study aimed to compare the clinical and radiological outcomes of distal clavicle fracture fixation with a hook plate versus the standard non-locking T-plate for unstable Neer type II fractures. METHODS: A prospective matched cohort study including two groups of hook plates and T-plates fixation was conducted in our two tertiary trauma centers. Patients with distal clavicle fractures Neer type II were assessed for union and the Constant-Murley score (CMS) at 1-, 3-, and 6-month follow-ups. Inadequate radiographic consolidation > 6 months after surgery was defined as non-union. Subscales of CMSpain, CMSactivities of daily living, CMSrange of motion (ROM), and CMSstrength were also compared between groups. According to recommendations, the implant was removed after union confirmation in the hook plate at a planned second surgery. RESULTS: Sixty consecutive patients were enrolled: 30 in the T-plate group and 30 in the hook plate group. CMS showed similar functional outcomes for T-plates and hook plates at all follow-ups (Month 6: 92.0 vs. 91.7, P = 0.45). However, on the month 1 follow-up, the T-plate group scored higher than the hook plate group for ROM and pain (CMSpain = 13.0 vs. 12.3, P = 0.03; CMSROM = 35.2 vs. 33.2, P = 0.002). Despite this, Pain, ROM, and other CMS domains were comparable between groups (P > 0.05). The mean time to union was 2.5 + 1.4 months for the T-plate group and 2.3 + 1.6 months for the hook plate group (P = 0.44). There was one fixation failure in each group and one periprosthetic fracture in the hook plate group (two revisions for the hook plates and one for T-plates, P = 1.00). Non-union and other complications were not observed. CONCLUSION: Both surgical approaches resulted in full recovery and good function. However, in the hook plate group ROM and pain scores were lower at 1 month. Standard non-locking T-plates are a viable alternative to hook plates with low cost and promising outcomes for treating displaced distal clavicle fractures.

Surgical versus conservative management of distal radius fracture with coronal shift; a randomized controlled trial.

BACKGROUND: Coronal shift is one of the most critical complications related to distal radius fracture (DRF), leading to instability in the distal radioulnar joint (DRUJ). Nevertheless, there is no unified approach for the managing DRF with coronal shift; therefore, the current study aims to compare the surgical versus conservative approach for the coronal shift due to DRF treatment. METHODS: This is a randomized clinical trial conducted on 50 patients with distal radius fracture (type 1 based on Fernandez Classification of Distal Radius Fractures) with a coronal shift in 2014-17. The patients were randomly allocated to treatment conservatively (n=25) by a long arm casting or surgically (n=25) using a volar plate fixation. The patients were followed for 24 months, and primary outcomes included a functional score on the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire; pain score based on the Visual Analogue Scale (VAS), and handgrip strength (HGS) measured via a dynamometer were assessed and compared. RESULTS: Both approaches led to significant improvement in range of motion, pain complaint, DASH scores, and HGS at the end of the two-year follow-up (P-value <0.05). The comparison of the trend of changes in the two groups generally revealed a remarkable better range of motions, VAS, and HGS among the operated cases (P-value <0.05); however, DASH score did not differ (P-value >0.05). CONCLUSION: The long-term outcomes of volar plate fixation for DRF management (bending fracture of metaphysis) plus coronal shift are notably superior to the conservative treatment; however, due to the limited information in this regard, further evaluations are strongly recommended.

Extensile approach versus minimally invasive technique in management of calcaneus fractures.

BACKGROUND: Calcaneus fracture is one of the important fractures in orthopedic surgery. Here we aimed to investigate and compare the extensile approach and minimally invasive technique in patients with calcaneus fractures. METHODS: This is a randomized clinical trial that was performed in 2019 in Kashani and Alzahra hospitals in Isfahan, Iran. The study population consisted of 30 patients with intraarticular calcaneus fractures. Thirty patients were divided into two groups. In the first group, surgery was performed using the minimally invasive technique and in the second group, the extensile approach was performed. Patients were followed for 12 months. Data regarding the duration of surgery, Boehler and Gisan angles, quality of joint reduction, subtalar joint movement, the incidence of soft-tissue complications and pain of the patients were measured and compare between two groups. RESULTS: A total number of 30 patients entered the study and were divided into two groups each containing 15 patients. The duration of operation in the extensile approach group was significantly higher than the minimally invasive group (P = 0.03). The severity of pain and mean Boehler angle were significantly higher in the minimally invasive group than in the extensile approach group (P = 0.001 and P = 0.002 respectively). The quality of reduction was also significantly better in the extensile approach group than minimally invasive (P = 0.01) but the extensile approach group had more soft tissue complications than the minimally invasive group (P = 0.006). CONCLUSION: Extensile approach was associated with lower pain, lower Boehler angle and better quality of reduction compared to minimally invasive technique but also higher operation duration and surgical site complications. We suggest that the extensile approach should be used in patients with calcaneus fractures with attention to possible complications.

Intraneural cavernous hemangioma: a rare case of extrafascicular left ulnar nerve tumor.

Hemangiomas are benign soft tissue tumors that may be found everywhere in the human body. As one of the hemangioma types, cavernous hemangioma consists of a flat endothelium along with blood-filled spaces and may be found in the central nervous system, but rarely occurs in peripheral nerves. This article pertains to the introduction of an old female patient complaining of pain and paresthesia of the ulnar side of the left forearm and hypothenar with numbness and tingling of the fourth and fifth digits and clawing. The patient was medically treated for a month but became a surgical candidate due to the poor response to medical treatment. A 1-cm lesion was observed in the surgery with compression on the ulnar nerve in the ulnar groove. Neurologic symptoms of the patient were improved after excision of the lesion, but clawing persisted.

Comparative analysis of surgical approaches in acetabular fractures: Blood loss and procedural efficiency.

Background: Acetabulum fractures pose significant challenges in orthopedic trauma due to anatomical complexity and the potential for iatrogenic injury to surrounding structures. The study aims to compare the outcomes of two surgical approaches, the ilioinguinal approach (IA) and the modified Stoppa approach (MSA), in managing acetabular fractures. Methods: A retrospective cohort study was conducted on 50 patients with anterior acetabular fractures. Demographic characteristics and perioperative data were collected, and the patients were categorized based on the applied surgical approach, either IA or MSA. Statistical tests were used for data analysis. Results: The MSA group showed significantly lower intraoperative blood loss compared to IA (MSA: 404.36 ± 151.94 ml, IA: 650.92 ± 136.33 ml, Δ = 246.56 ml, P < 0.001). The mean procedure duration for MSA was 141.88 ± 27.12 min, compared to 172.24 ± 32.69 min for IA (P = 0.37). The incidence of soft tissue infection (MSA: 8 %, IA: 8 %) and sciatic nerve injury (both 0 %) exhibited no significant differences (P > 0.99). Postoperative assessments, Harris Hip Scores (MSA: 90.08 ± 6.26, IA: 89.29 ± 6.64, P = 0.66) and Modified Merle d'Aubigné Scores (MSA: 14.86 ± 1.37, IA: 15.23 ± 1.16, P = 0.40), showed no substantial variance between groups. Conclusion: The study suggests that the MSA approach demonstrated superiority, particularly due to significantly less intraoperative blood loss. Further comprehensive studies are recommended to validate and generalize these findings.