Robotic Arm-Assisted Total Knee Arthroplasty: Anatomical Alignment and Mid-Term Outcomes from the First Cohort Originating in Greece.

Robotic arm-assisted total knee arthroplasty (RATKA) represents a haptic assistive robotic arm used for bone preparation. The purpose of this study was to present implant survivorship, complications and evaluate patients' satisfaction, clinical and functional outcome of RATKA with a minimum of 1-year follow-up. The Oxford Knee Score was recorded preoperatively and at last follow-up. Patients' satisfaction rates, as well as complications and re-operations were studied. Anatomical alignment including varus, valgus deformities and flexion, extension, pre-and postoperatively were evaluated. A total of 156 patients with mean age = 71.9 years were included in the study. The mean follow-up was 35.7 months, while one revision was performed due to infection. Statistically significant improvement of the Oxford Knee Score, as well as of the knee alignment deformities were recorded, while 99.4% of patients reported to be "very satisfied" or "satisfied" with the procedure. RATKA seems to be a safe, as well as reproductible procedure at short-and mid-term follow-up, while the accurate implant positioning may lead to favorable long-term outcomes.

Hippocrates: A Pioneer in Orthopaedics and Traumatology.

PURPOSE: Hippocrates, the ancient Greek physician, is considered the father of Medicine; however, his contributions to Orthopaedics and Traumatology have not been highlighted enough. The present historical review represents an effort to present and categorize his work, in this field, per clinical disorder and anatomical region. METHODS: The "Hippocratic Corpus" original text was thoroughly studied to identify all Hippocrates' contributions in Orthopaedics and Traumatology. Volume III of his works, especially "On Fractures", "On Joints", and "Mochlicon" includes a plethora of information regarding the management of traumas, as well as other disorders and clinical entities of the musculoskeletal system. RESULTS: In particular, Hippocrates describes reduction techniques for fractures, as well as joint dislocations, elaborates on the biology of the fractures' healing process and the basic principles of fracture management and fixation, presents the signs and symptoms of gangrene, teaches the treatment of osseous infections and offers valuable insight on the biomechanics and treatment of spinal diseases. CONCLUSIONS: Hippocrates' contributions in Orthopaedics and Traumatology are unprecedented, making him a true pioneer in this field, while the basic principles that he presented were further studied and confirmed in the 19th and 20th centuries.

Suggestion of a Novel Classification Based on the Anatomical Region and Type of Bilateral Fatigue Femoral Fractures.

Purpose: Bilateral fatigue femoral fractures (BFFF) represent an extremely rare clinical entity. The present study introduces a novel classification, in order to categorize the BFFFs and provide a thorough review of all these, so far in the literature, reported cases. Methods: The BFFF were classified taking into account the anatomical region of the femoral fracture; (fh): femoral head, (sc): sub-capital, (pt): peri-trochanteric, (st): sub-trochanteric, (s): shaft, (d): distal femur and the fracture type (complete or incomplete); type I: bilateral incomplete fractures, type II: unilateral incomplete fracture, and type III: bilateral complete fractures. Type III was further subdivided into type IIIA: bilateral non-displaced fractures, type IIIB: unilateral displaced fracture, and type IIIC: bilateral displaced fractures. Furthermore, a meticulous review of the PubMed and MEDLINE databases was conducted to locate all articles reporting these injuries. Results: A total of 38 patients (86.8% males), with a mean age of 25.3 years, suffering BFFFs were identified from the literature search. The mean time interval from symptoms' onset to diagnosis was 54 days. According to the proposed classification, 2.6% of the fractures were categorized as type I (h), 36.8% as type I (sc), 2.6% as type I(st/s), 7.9% as type I (s), 2.6% as type I (d), 5.4% as type II (fh), 26.3% as type II (sc), 2.6% as type IIIA (st), 2.6% as type IIIA (d), 5.4% as type IIIB (sc), 2.6% as type IIIB (d) and 2.6% as type IIIC (sc). Surgery was performed in 52.6%, while non-operative treatment was followed in 47.4% of the population. Regarding the fracture type, 75% of type I fractures were conservatively treated, while 91.7% and 66.6% of type II and III fractures were surgically treated. For patients treated conservatively, the mean time from diagnosis to return to previous status was 260 days, while for patients treated surgically, 343 days. Conclusions: BFFFs, although rare, may pose a diagnostic and therapeutic challenge. The present classification offers valuable information and may act as a guide for the management of these patients.

Nutritional assessment and quality of life in patients with non-small cell lung cancer undergoing immunotherapy.

BACKGROUND: Patients with metastatic non-small cell lung cancer (NSCLC) often experience severe eating disorders and other problems because of rapid disease progression and various therapies, which significantly affect their quality of life (QoL). AIMS: This study aimed to assess the nutritional status and QoL of patients with NSCLC at the start of immunotherapy and 3 months later. METHODS: This study used a prospective, observational, consecutive sampling approach and was carried out between July 2018 and August 2019. The convenience sample comprised 60 patients treated in the oncology ward and the day care department of a public hospital in Greece. Their nutritional status was assessed using the Mini Nutritional Assessment questionnaire and their QoL using the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire and its QLQ-LC13 module. They were evaluated at the start of immunotherapy (phase I) and 3 months later (phase II). FINDINGS: Of the initial 60 patients, 25% had died and 23.3% declined to participate by phase II. Of the 31 patients (51.7%) who completed the study, 64.5% had been assessed as malnourished at phase I; at phase II, this had decreased to 32.3%, so nutritional status appeared to have significantly improved. There were also significant improvements between phases I and II in global health status/QoL, as well as in the physical, roles, emotional and social dimensions. Additionally, all nine symptoms of QLQ-C30 significantly decreased, while the QLQ-LC13 showed significant improvements in dyspnoea, alopecia and pain in parts of the body other than the chest, arm or shoulder. CONCLUSION: Metastatic NSCLC patients' QoL and nutritional status significantly improved after 3 months' immunotherapy.

Soleus Muscle Single Metastasis from Hepatocellular Carcinoma.

Extrahepatic metastases of hepatocellular carcinoma (HCC) are associated with poor prognosis, while such lesions in skeletal muscles are extremely rare. A unique case of skeletal metastasis in the soleus muscle in a 76-year-old male patient with HCC is reported. The patient presented with a painful palpable mass in his left calf. Magnetic resonance imaging (MRI) revealed a contrast-enhancing lesion in the soleus muscle, while core needle biopsy showed metastatic lesion from the HCC. Due to the poor overall condition of the patient, no further treatment was performed, while he passed away three months later. Hepatocellular carcinoma represents an aggressive tumor, with poor prognosis, especially in cases of extra-hepatic metastases. Such lesions have a reported incidence of about 15%. Extra-hepatic metastasis to the skeletal muscles is extremely rare, with only 21 more such cases reported in the literature so far. No clear therapeutic strategies exist for such cases. Thus, it is of utmost importance to detect similar cases in early stages for a possible better prognosis and clearer understanding of the therapeutic options, including surgical and loco-regional treatments.

Correlation of Cruciate Ligament Histological Findings with Coronal Plane Deformities and Characteristics of Patients Undergoing Total Knee Arthroplasty.

Introduction:Osteoarthritis (OA) is a leading cause of disability in older adults. The majority of cruciate ligament injuries progress to OA through numerous mechanisms. The aim of this study was to identify the histological changes of cruciate ligaments in OA knees from patients undergoing total knee arthroplasty (TKA) as well as possible correlations with coronal plate deformities and patients' characteristics. Methods:A total of 50 consecutive patients with knee OA undergoing TKA with posterior stabilized prosthesis were included in the study. Demographics, preoperative range of flexion, the flexion contracture, Visual Analogue Scale (VAS) score, coronal plane deformity, Kellgren and Lawrence radiological degree of OA and Beguin-Locker classification of intraoperative degree of OA were recorded. The histopathological changes evaluated in specimens from both cruciate ligaments included myxoid and mucoid degeneration, chondroid metaplasia and orientation of collagen fibers. Results:A total of 24 males (48%) and 26 females (52%) with a mean age of 71 years (SD 5.93) participated in our study. The mean preoperative duration of pain was 3.62 years (SD 2.2). The K-L scale mean score was 2.60 (SD 0.64) and the mean VAS score 6.38 (SD 1.1). The mean varus deformity was 10.14 degrees (SD 3.7). Knee flexion/flexion contracture were recorded at 95.76±6.183 and 16.14±4.914 degrees, respectively. Intraoperatively, the B-L scale mean score was 2.02 (SD 0.77). Mucoid degeneration in ACL was the most common histopathological feature (15.7%) (SD 12.9), followed by chondroid metaplasia in both ACL and PCL [14.3% (SD12.5) and 14.3% (SD 13.2), respectively]. A negative correlation between BMI and myxoid ACL (p=0.01) as well as between varus deformity and mucoid ACL (p=0.05) was found, while a negative correlation between height and myxoid ACL (p=0.05) has been also revealed. Conclusion:Degeneration of cruciate ligaments is associated with degenerative joint disease and OA should be considered a disease involving the whole joint including ligaments, menisci, synovium and joint capsule. However, the correlation between degeneration of cruciate ligaments and OA is not yet fully understood and more research is needed.

Fungal Prosthetic Joint Infection in Revised Knee Arthroplasty: An Orthopaedic Surgeon's Nightmare.

Fungal prosthetic joint infections (PJIs), despite the fact that they are rare, represent a devastating complication. Such infections in revised knee arthroplasties pose a unique surgical and medical challenge. A rare case of Candida parapsilosis PJI in revised knee arthroplasty is reported. Furthermore, a thorough review of all published fungal PJIs cases in revised knee arthroplasties is provided. A 72-year-old female with total knee replacement surgery due to osteoarthritis 10 years ago, followed by two revision surgeries six and two years ago due to aseptic loosening, presented with signs and symptoms of septic loosening of the knee components. Resection arthroplasty and cement-spacer placement was performed and periprosthetic tissue cultures yielded Candida parapsilosis. The patient was commenced on proper antifungal treatment (AFT) for six months and then the second stage of the revision surgery was performed successfully. From 2000 to 2022, a total of 46 patients with median age 69 years [interquartile range (IQR = 10)], suffering fungal PJI occurring in revised knee arthroplasty have been reported. The median time from initial arthroplasty to symptoms' onset was 12 months (IQR = 14). Cultures of local material (52.2%) and histology (6.5%) were the reported diagnostic method, while Candida species were the most commonly isolated fungi. Regarding surgical management, two-stage revision arthroplasty (TSRA) was performed in most cases (54.3%), with median time-interval of six months (IQR = 6) between the two stages. Regarding AFT, fluconazole was the preferred antifungal compound (78.3%), followed by voriconazole and amphotericin B (19.6% each). The median duration of AFT was five months (IQR = 4.5). Infection's outcome was successful in 38 cases (82.6%). Fungal PJIs, especially in revised knee arthroplasties, are devastating complications. A combination of AFT and TSRA seems to be the treatment of choice. TSRA in these cases poses a special challenge, since major bone defects may be present. Therapeutic procedures remain unclear, thus additional research is needed.

Knee Septic Arthritis Caused by Pantoea agglomerans.

Introduction: Septic arthritis usually affects native joints and represents an invasion of the joint space by a wide variety of microorganisms, most commonly bacteria, such as Staphylococci, Streptococci, and Gram-negative rods. An extremely rare case of septic knee arthritis caused by Pantoea agglomerans in a 67-year-old male is presented. Case Report: The patient was initially treated with arthroscopic debridement, but due to persistent symptomatology open surgical debridement 3 days after initial surgery was also performed. Cultures yielded P. agglomerans and Streptococcus agalactiae. He was commenced on causative antimicrobial treatment including intravenous linezolid, ciprofloxacin, and clindamycin. He was discharged 10 days later, on oral linezolid and ciprofloxacin for 3 months. Conclusion: Delayed diagnosis in septic arthritis cases and inadequate control of the infection may lead to insufficient treatment and devastating consequences for the patient. The treatment includes surgical debridement and proper antimicrobial agents. Cultures dictate the proper treatment; hence, microbiological examination is of utmost importance, since it may reveal unusual organisms for which empirical treatment may prove insufficient.

Native Joint Infections by Aspergillus Species.

BACKGROUND: Septic arthritis due to Aspergillus spp. represents a rare, but severe disease. Nevertheless, clear guidelines regarding most effective medical treatment have not yet been established. The present study is a literature review of all reported cases of fungal septic arthritis due to Aspergillus spp, in order to clarify epidemiology, as well as the medical and operative management and their outcome. METHODS: A meticulous review of all published septic arthritis infections due to Aspergillus has been conducted. Information regarding demographics, causative fungus, antifungal treatment (AFT), surgical intervention, as well as the infection's outcome were recorded and evaluated. RESULTS: A total of 30 Aspergillus spp. strains from 29 hosts have been studied. The patients' mean age was 45.8 years. The most commonly affected joint was the knee (45.7%), while the predominant symptom was joint pain (62%). Most patients were immunocompromised (72.4%). Diagnosis was established through cultures and/or histopathology. Aspergillus fumigatus was the most common responsible fungi (63.3%), followed by A. flavus (16.6%) and A. terreus (10%). Regarding AFT, the preferred agent proved to be Amphotericin B (14 cases; 48.3%), followed by voriconazole (11; 37.9%), while the mean AFT duration was 5.6 months. In most cases surgical treatment was also performed (in 4 cases no surgery was reported). Treatment was effective in 20 cases (69%). CONCLUSIONS: Septic arthritis caused by Aspergillus spp. represents a severe clinical entity. It seems that, with the available data, prolonged AFT along with surgical intervention is the preferred management of this infection, while identification of the responsible fungus is of utmost importance.

Spondylodiscitis Caused by Aspergillus Species.

BACKGROUND: Spondylodiscitis caused by Aspergillus spp. is a rare but life-threatening clinical entity. However, a consensus on diagnostic criteria and most effective medical management is still missing. The present study is a review of all published cases of spondylodiscitis caused by Aspergillus spp., in an effort to elucidate epidemiology, patients' characteristics, andand the medical and surgical treatment options and their effectiveness. METHODS: A thorough review of all existing spondylodiscitis cases caused by Aspergillus was performed. Data regarding demographics, responsible fungus, time between symptoms' onset and firm diagnosis, antifungal treatment (AFT), surgical intervention, andand the infection's outcome were investigated. RESULTS: A total of 118 Aspergillus spondylodiscitis cases, yielding 119 Aspergillus spp. isolates, were identified in the literature. The patients' mean age was 40.6 years. Magnetic resonance imaging (MRI) (after its introduction) indicated the diagnosis in most cases (66.7%), while definite diagnosis was established through cultures in the majority of cases (73.7%). Aspergillus fumigatus was isolated in most cases (73; 61.3%), followed by Aspergillus flavus (15; 12.6%) andand Aspergillus nidulans and terreus (7; 5.9%, each). The mean time between symptoms' onset and diagnosis was 5.7 months. Amphotericin B was the preferred antifungal regiment (84 cases; 71.2%), followed by voriconazole (31; 26.3%), and the mean AFT duration was 6.1 months. The final outcome was successful in 93 cases (78.8%). Furthermore, 77 patients (65.3%) underwent surgery. CONCLUSIONS: Spondylodiscitis caused by Aspergillus spp. represents a clinical challenge, requiring a multidisciplinary approach. The present review has shown that prolonged AFT has been the standard of care of the studied cases, while surgical treatment seems to play an important role in selected patents.

Finite Element Method for the Evaluation of the Human Spine: A Literature Overview.

The finite element method (FEM) represents a computer simulation method, originally used in civil engineering, which dates back to the early 1940s. Applications of FEM have also been used in numerous medical areas and in orthopedic surgery. Computing technology has improved over the years and as a result, more complex problems, such as those involving the spine, can be analyzed. The spine is a complex anatomical structure that maintains the erect posture and supports considerable loads. Applications of FEM in the spine have contributed to the understanding of bone biomechanics, both in healthy and abnormal conditions, such as scoliosis, fractures (trauma), degenerative disc disease and osteoporosis. However, since FEM is only a digital simulation of the real condition, it will never exactly simulate in vivo results. In particular, when it concerns biomechanics, there are many features that are difficult to represent in a FEM. More FEM studies and spine research are required in order to examine interpersonal spine stiffness, young spine biomechanics and model accuracy. In the future, patient-specific models will be used for better patient evaluations as well as for better pre- and inter-operative planning.