Outcomes and Patient Safety in Overlapping vs. Nonoverlapping Total Joint Arthroplasty: A Systematic Review and Meta-Analysis.

INTRODUCTION: Overlapping surgery is defined as two cases occurring in separate operating rooms (ORs), where the same attending surgeon conducts the critical surgical portions of each case at different times. Although it has been suggested that this established practice may improve the utilization of resources, allow for more opportunities to teach surgical trainees, and facilitate timely access to care, there is still no consensus on its use in elective orthopaedic surgery, such as total joint arthroplasty (TJA). METHODS: A systematic review and meta-analysis of the literature was done according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify articles investigating the use of overlapping and single operating room TJA. Relevant data, including surgical time, intraoperative complications, postoperative complications, mortality rate, revision rate, and readmission rate, were extracted and recorded. RESULTS: Six articles were included (35,938 patients: 17,677 overlapping and 18,261 nonoverlapping). Overall revision rates were 1.2% and 1.1% for the overlapping and nonoverlapping cohorts, respectively (odds ratio [OR] = 1.19; 95% confidence interval [CI]: 0.93 to 1.53). The overall intraoperative complication rate was 1.6% for both cohorts (OR = 0.98; 95% CI: 0.79 to 1.23), and the overall postoperative orthopaedic complication rates were 2.0% and 1.95% within the overlapping and nonoverlapping OR cohorts, respectively (OR = 1.07; 95% CI: 0.89 to 1.29). The readmission rate was 4.6% in the overlapping group and 4.2% in the nonoverlapping group (OR = 0.88; 95% CI: 0.70 to 1.11). Two studies with comparable groups reported markedly increased surgical time in the overlapping group compared with the nonoverlapping group. DISCUSSION: Overlapping surgery was found to be as safe as nonoverlapping surgery in patients undergoing TJA. Although overlapping TJA surgery is associated with satisfactory short-term revision rates, prolonged follow-up is required to further assess the medium-term and long-term outcomes of overlapping surgery compared with nonoverlapping surgery. Finally, although overlapping TJA surgery might be associated with increased OR time, this difference is not clinically relevant.

Pioneer Female Orthopedic Surgeons as Role Models.

Maud Forrester-Brown in the United Kingdom (1921), Marika Daniilidou in Greece (1932), Ruth Jackson in the United States (1932), Loris Figgins in Australia (1957), and Evalina Burger in South Africa (1993) all chose to specialize in orthopedics. Although there are dynamic female leaders in orthopedic surgery, the field continues to present obstacles to women. Role models, mentors, and exposure to the field have been lacking for women. Although improvements have occurred in the past few decades, further changes are necessary to attract, develop, and retain qualified female candidates. [Orthopedics. 2020; 43(1):e8-e14.].

Giant Cell Tumor of Soft Tissue: A Rare Entity.

Giant cell tumor (GCT) of the soft tissue (GCT-ST) is a rare, unusual primary soft tissue tumor that is completely distinct from, and should not be confused with, any giant cell-rich tumor of bone or soft tissue. Currently, GCT-ST is included in the group of so-called fibrohistiocytic tumors of intermediate (borderline) malignancy. The most common symptom is a painless, slow-growing mass in a superficial location. Computed tomography and magnetic resonance imaging show a solid, nonhomogeneous, frequently hemorrhagic mass. Differential diagnosis is broad and should include benign and malignant entities. The treatment and excision margins of GCT-ST are controversial. Incomplete surgical excision is usually followed by local recurrence. Biological behavior is unpredictable. Giant cell tumor of the soft tissue has shown a lower mean local recurrence rate compared to GCT of bone but has a higher metastatic and death rate. Therefore, close clinical follow-up is recommended. [Orthopedics. 2019; 42(4):e364-e369.].

Reduction techniques for difficult subtrochanteric fractures.

Subtrochanteric fractures can result from high-energy trauma in young patients or from a fall or minor trauma in the elderly. Intramedullary nails are currently the most commonly used implants for the stabilization of these fractures. However, the anesthetic procedure for the patients, the surgical reduction and osteosynthesis for the fractures are challenging. The anesthetic management of orthopedic trauma patients should be based upon various parameters that must be evaluated before the implementation of any anesthetic technique. Surgery- and patient-related characteristics and possible comorbidities must be considered during the pre-anesthetic evaluation. Adequate fracture reduction and proper nail entry point are critical. Understanding of the deforming forces acting on various fracture patterns and knowledge of surgical reduction techniques are essential in obtaining successful outcomes. This article discusses the intraoperative reduction techniques for subtrochanteric fractures in adults and summarizes tips and tricks that the readers may find useful and educative.

Total Scapulectomy and Shoulder Reconstruction Using a Scapular Prosthesis and Constrained Reverse Shoulder Arthroplasty.

Malignant tumors of the scapula are rare, and limb salvage surgery after tumor resection is challenging. The authors present a series of 6 patients who were treated by total scapulectomy and reconstruction with a custom-made scapular prosthesis and a constrained reverse shoulder arthroplasty. Postoperative oncologic and functional outcomes were assessed. The mean follow-up was 37 months (range, 9-84 months). Clear surgical margins were achieved in all patients. At the last follow-up, 4 patients showed no evidence of disease and 2 had died of systemic metastatic disease. Although shoulder function was limited, all shoulders were painless and stable and the patients retained satisfactory hand, wrist, and elbow function. [Orthopedics. 2018; 41(6):e888-e893.].

Rare diseases of bone: Erdheim-Chester and Rosai-Dorfman non-Langerhans cell histiocytoses.

Non-Langerhans cell histiocytosis (N-LCH) summarizes a group of rare diseases with different clinical presentations, pathogenesis and morphology. These include primary cutaneous N-LCH, cutaneous N-LCH with systemic involvement, and primary extracutaneous systemic forms with occasional cutaneous involvement.The juvenile (JXG) and non-juvenile xanthogranuloma (N-JXG) family of histiocytoses are N-LCH: the JXG family consisting of the JXG (cutaneous), xanthoma disseminatum (cutaneous and systemic) and Erdheim-Chester disease (ECD; systemic); and the N-JXG family consisting of the solitary reticulohistiocytoma (cutaneous), multicentric reticulohistiocytosis (cutaneous and systemic) and Rosai-Dorfman disease (RDD; systemic).ECD is a clonal disorder from the JXG family of N-LCH; RDD is a reactive proliferative entity from the non-juvenile xanthogranuloma family of N-LCH.ECD and RDD N-LCH are rare disorders, which are difficult to diagnose, with multi-organ involvement including bone and systemic symptoms, and which respond to therapy in an unpredictable way.The key to successful therapy is accurate identification at tissue level and appropriate staging. Patients should be observed and monitored in a long-term pattern. Prognosis depends on disease extent and the organs involved; it is generally good for RDD disease and variable for ECD. Cite this article: EFORT Open Rev 2018;3:381-390. DOI: 10.1302/2058-5241.3.170047.

Spondylitis transmitted from infected aortic grafts: a review.

Graft infection following aortic aneurysms repair is an uncommon but devastating complication; its incidence ranges from <1% to 6% (mean 4%), with an associated perioperative and overall mortality of 12% and 17.5-20%, respectively. The most common causative organisms are Staphylococcus aureus and Escherichia coli; causative bacteria typically arise from the skin or gastrointestinal tract. The pathogenetic mechanisms of aortic graft infections are mainly breaks in sterile technique during its implantation, superinfection during bacteremia from a variety of sources, severe intraperitoneal or retroperitoneal inflammation, inoculation of bacteria during postoperative percutaneous interventions to manage various types of endoleaks, and external injury of the vascular graft. Mechanical forces in direct relation to the device were implicated in fistula formation in 35% of cases of graft infection. Partial rupture and graft migration leading to gradual erosion of the bowel wall and aortoenteric fistulas have been reported in 30.8% of cases. Rarely, infection via continuous tissues may affect the spine, resulting in spondylitis. Even though graft explantation and surgical debridement is usually the preferred course of action, comorbidities and increased perioperative risk may preclude patients from surgery and endorse a conservative approach as the treatment of choice. In contrast, conservative treatment is the treatment of choice for spondylitis; surgery may be indicated in approximately 8.5% of patients with neural compression or excessive spinal infection. To enhance the literature, we searched the related literature for published studies on continuous spondylitis from infected endovascular grafts aiming to summarize the pathogenesis and diagnosis, and to discuss the treatment and outcome of the patients with these rare and complex infections.

Posterior shoulder fracture-dislocation: an update with treatment algorithm.

Posterior shoulder fracture-dislocation is a rare injury accounting for approximately 0.9 % of shoulder fracture-dislocations. Impression fractures of the articular surface of the humeral head, followed by humeral neck fractures and fractures of the lesser and grater tuberosity, are the more common associated fractures. Multiple mechanisms have been implicated in the etiology of this traumatic entity most commonly resulting from forced muscle contraction as in epileptic seizures, electric shock or electroconvulsive therapy, major trauma such as motor vehicle accidents or other injuries involving axial loading of the arm, in an adducted, flexed and internally rotated position. Despite its' scarce appearance in daily clinical practice, posterior shoulder dislocation is of significant diagnostic and therapeutic interest because of its predilection for age groups of high functional demands (35-55 years old), in addition to high incidence of missed initial diagnosis ranging up to 79 % in some studies. Several treatment options have also been proposed to address this type of injury, ranging from non-surgical methods to humeral head reconstruction procedures or arthroplasty with no clear consensus over definitive treatment guidelines, reflecting the complexity of this injury in addition to the limited evidence provided by the literature. To enhance the literature, this article aims to present the current concepts for the diagnosis, evaluation and treatment of the patients with posterior fracture-dislocation shoulder, and to present a treatment algorithm based on the literature review and our own experience.

Four-corner fusion of the wrist: clinical and radiographic outcome of 31 patients.

BACKGROUND: Four-corner fusion is a rational surgical option for the management of degenerative conditions of the wrist. Most related studies have compared four-corner fusion with scaphoid excision or proximal row carpectomy, with a variety of reported results. To enhance the literature, we performed this study to evaluate a series of patients with degenerative conditions of the wrist treated with four-corner fusion using 3 surgical techniques and to discuss the clinical and radiographic outcome of the patients. MATERIALS AND METHODS: We retrospectively studied 31 patients (24 men, 7 women; mean age, 43 years; 9 heavy manual laborers) who underwent four-corner fusion of their wrists for degenerative conditions from 2005 to 2015. Internal fixation was done using multiple Kirschner wires (14 patients), headless compressive screws (8 patients), or a circular plate (9 patients). Mean follow-up was 4 years (1-11 years). We evaluated the clinical outcome with the Patient-Rated Wrist Evaluation (PRWE) score and fusion with radiographs. RESULTS: All patients experienced improvement of their pain, function, range of motion and grip strength (p < 0.05). Twenty-three patients (74 %) reported no pain, and eight patients reported mild, occasional pain. Twenty-one patients (68 %) were able to do usual and specific activities. Mean wrist motion improved to 70 % and mean grip strength improved to 85 % of opposite wrist. Two heavy manual labor patients requested a job modification because of wrist impairment. Radiographs of the wrist showed fusion of all fused joints in 28 (90.3 %) patients and partial fusion in three patients (9.7 %). No patient with partial fusion required a reoperation for symptomatic nonunion until the period of this study. Three patients experienced complications (10 %). Two patients treated with a circular plate experienced complex regional pain syndrome and painful implant impingement; another patient treated with Kirschner wires and headless compression screws experienced radiolunate arthritis from impingement of the lunate screw to the radius. CONCLUSIONS: Four-corner fusion is a reliable limited wrist fusion technique that provides pain relief, grip strength and satisfactory range of motion in patients with degenerative conditions of the wrist. Partial union is more common with Kirschner wire fixation and complications are more common with circular plate fixation.

Tuberculous Spondylitis of the Craniovertebral Junction.

Craniovertebral junction tuberculosis is rare, accounting for 0.3 to 1% of all tuberculous spondylitis cases. MR imaging is the modality of choice to detect bone involvement, abscess formation and subligamentous spreading of the pus, to differentiate from other lesions affecting the craniovertebral junction, and to determine the efficacy of treatment. Given the fact that surgical treatment of patients with craniovertebral junction tuberculosis has been associated with a high mortality rate ranging up to 10% and recurrence rate ranging up to 20%, conservative is the standard of treatment for most patients. This article presents a patient with craniovertebral junction Mycobacterium tuberculosis infection diagnosed with CT-guided biopsy. A halo vest was applied and antituberculous treatment with rifampicin, isoniazid and ethambutol was initiated. At 6-month follow-up, the patient was asymptomatic; CT of the cervical spine showed healing of the bony lesions. The halo vest was removed and physical therapy was recommended. Antituberculous treatment was continued for a total of 18 months, without any evidence of infection recurrence.