Risk Factors for a Failed Transmetatarsal Amputation in Patients with Diabetes.

BACKGROUND: Transmetatarsal amputation (TMA) is a well-recognized limb-salvage procedure, often indicated for the treatment of diabetic foot infections. Currently, there is no widespread agreement in the literature with regard to the factors associated with failure of TMA. This study aimed to define risk factors for the failure of TMA, defined as below-the-knee or above-the-knee amputation, in patients with diabetes. METHODS: This retrospective cohort study included 341 patients who underwent primary TMA. Patients who had a revision to a higher level (the failed TMA group) were compared with those who did not have failure of the initial amputation (the successful TMA group). RESULTS: This study showed a higher frequency of renal impairment, defined as a high creatinine level and/or a previous kidney transplant or need for dialysis, in the failed TMA group (p = 0.002 for both). Furthermore, a Charlson Comorbidity Index (CCI) threshold value of 7.5 was identified as the optimal predictive value for failure of TMA (p = 0.002), and patients with a CCI of >7.5 had a median time of 1.13 months until the initial amputation failed. CONCLUSIONS: TMA is associated with a high risk of revision. CCI may be used as a preoperative selection criterion, as 71.8% of patients with a CCI of >7.5 had failure of the TMA. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Editorial Commentary: Machine Learning Can Indicate Hip Arthroscopy Procedures, Predict Postoperative Improvement, and Estimate Costs.

Complex statistical approaches are increasingly being used in the orthopaedic literature, and this is especially true in the field of sports medicine. Tools such as machine learning provide the opportunity to analyze certain research areas that would often require the complex assessment of large amounts of data. Generally, decision making is multifactorial and based upon experience, personal capabilities, available utilities, and literature. Given the difficulty associated with determining the optimal patient treatment, many studies have moved toward more complex statistical approaches to create algorithms that take large amounts of data and distill it into a formula that may guide surgeons to better patient outcomes while estimating and even optimizing costs. In the future, this clinical and economic information will play an important role in patient management.

A comparison between Austin-Moore and Corail prosthesis regarding intraoperative periprosthetic femur fractures in hip hemiarthroplasty.

Hip hemiarthroplasty is considered the treatment of choice for displaced femoral neck fractures in elderly less active patients. One important complication of this procedure is an intraoperative periprosthetic femur fracture (IPF), which may lead to poor functional outcome and may increase morbidity and mortality. Our primary aim in this study is to compare between Austin-Moore and Corail prosthesis regarding IPFs. Our secondary aim is to assess patient and surgical technique related risk factors for the development of this complication. Inclusion criteria included patients older than 65 years of age who had a displaced femoral neck fracture and were operated for hip hemiarthroplasty between the years 2014-2018. Patient-specific data was collected retrospectively including age, gender, comorbidities, pre-injury ambulatory status, duration of surgery, surgical approach, use of Austin-Moore or Corail prosthesis, surgeon's experience and type of anesthesia applied. In addition, radiographs were reviewed for measurement of calcar to canal ratio (CDR) and classification of Dorr canal type. 257 patients with an average age of 83.7 years were enrolled in the study. 118 patients (46%) were treated with an Austin-Moore prosthesis, while 139 (54%) were treated with a Corail prosthesis. A total of 22 patients (8.6%) had intraoperative fractures. Fracture prevalence was significantly higher in the Corail group compared with the Austin-Moore group (12.2% vs. 4.2%, p = 0.025). The majority of patients had a Dorr A type femoral canal, while the rest had Dorr B type canal (70% vs. 30%). There was no difference in fracture prevalence between Dorr A and B canal type patients. We didn't find any significant risk factor for developing an IPF, neither patient wise (age, gender, and comorbidities) nor surgical technique related (surgical approach, type of anesthesia, and surgeon's experience). Intraoperative periprosthetic fracture prevalence was significantly higher in the Corail patient group compared with the Austin-Moore group. This may be an important advantage of the Austin-Moore prosthesis over the Corail prosthesis.

Knee arthroplasty with hardware removal: complication cascade. Is it preventable?

An elderly woman underwent hardware removal and total joint replacement (TJR) of her right knee. Ipsilateral total tip replacement was performed 7 years earlier, and 12 months later, a supracondylar fracture of the index femur was successfully treated by open reduction internal fixation (ORIF) of the distal femur with a locking compression plate condylar plate. Hardware removal attempt, prior to the arthroplasty, resulted in fracture of the distal femur. Total knee replacement (TKR) was commenced with temporary reduction and final stabilisation of the femur fracture with a condylar plate. Postoperatively, non-union of the femur fracture developed twice with fatigue failure of the plate fixation device in both instances. Refixation of the femur was performed on both occasions and additional bone healing augmentation measures were performed for each subsequent surgery. Femur union was achieved fourteen months after the last surgery.

There Is No Place Like Home: A Survey on Satisfaction and Reported Outcomes of a Home-Based Rehabilitation Program Among Orthopedic Surgery Patients.

BACKGROUND: Home-based rehabilitation (HBR) was previously found to be associated with positive outcomes that are equal to inpatient rehabilitation. Few studies have examined the challenges patients are facing during rehabilitation and recovery and their satisfaction from HBR. OBJECTIVE: The purpose of this study was to examine the overall satisfaction and reported outcomes of HBR. METHODS: A telephone survey was conducted among 146 orthopedic surgery patients who participated in an HBR program, at the end of the HBR and 6 months after. The questionnaire included information about level of independence, satisfaction from HBR, and difficulties during HBR. FINDINGS: The overall satisfaction was high (73.1%). Patients reported on improvements in level of independence between the time of hospital discharge, the end of the program (P = .0001), and the 6 months follow-up (P = .004). Long wait for beginning of HBR, being a widower, and residing in a facility or with a nonfamilial caregiver were associated significantly with less general well-being and independence. The repeated measures analysis showed age lower than 71 and private health insurance ownership were associated with a better recovery. The most common difficulties reported were physical difficulties, lack of function, and caregivers' burden. CONCLUSIONS: Patients and families need more emotional, social, and physical support during HBR. The increase in health services delivered in community settings requires a more clear-cut policy and supervision for HBR and the follow-up services.

[A NEW PLAYER IN THE FIELD OF SHOULDER SURGERY - THE REVERSE SHOULDER ARTHROPLASTY].

INTRODUCTION: Reverse shoulder arthroplasty (RSA) in its modern design was first introduced over 25 years ago and approved by the American FDA over ten years ago. This type of prosthesis allows treatment of glenohumeral joint disease among patients with severe rotator cuff deficiency once thought to be inoperable. Modifications to the prosthesis design, along with improved surgical technique, led to better clinical outcomes and lower complication rates, which subsequently led to an increase in the usage of this implant device. The promising results led shoulder specialists to re-assess and expand the indications for surgery, which currently also include complex fractures of the proximal humerus in the elderly population. In this review we will cover the history and evolution of the RSA prosthesis, indications and contraindications, along with up-to-date outcomes and complications.

Reliability of smartphone-based teleradiology for evaluating thoracolumbar spine fractures.

BACKGROUND CONTEXT: Timely interpretation of computed tomography (CT) scans is of paramount importance in diagnosing and managing spinal column fractures, which can be devastating. Out-of-hospital, on-call spine surgeons are often asked to evaluate CT scans of patients who have sustained trauma to the thoracolumbar spine to make diagnosis and to determine the appropriate course of urgent treatment. Capturing radiographic scans and video clips from computer screens and sending them as instant messages have become common means of communication between physicians, aiding in triaging and transfer decision-making in orthopedic and neurosurgical emergencies. PURPOSE: The present study aimed to compare the reliability of interpreting CT scans viewed by orthopedic surgeons in two ways for diagnosing, classifying, and treatment planning for thoracolumbar spine fractures: (1) captured as video clips from standard workstation-based picture archiving and communication system (PACS) and sent via a smartphone-based instant messaging application for viewing on a smartphone; and (2) viewed directly on a PACS. STUDY DESIGN: Reliability and agreement study. PATIENT SAMPLE: Thirty adults with thoracolumbar spine fractures who had been consecutively admitted to the Division of Orthopedic Surgery of a Level I trauma center during 2014. OUTCOME MEASURE: Intraobserver agreement. METHODS: CT scans were captured by use of an iPhone 6 smartphone from a computer screen displaying PACS. Then by use of the WhatsApp instant messaging application, video clips of the scans were sent to the personal smartphones of five spine surgeons. These evaluators were asked to diagnose, classify, and determine the course of treatment for each case. Evaluation of the cases was repeated 4 weeks later, this time using the standard method of workstation-based PACS. Intraobserver agreement was interpreted based on the value of Cohen's kappa statistic. The study did not receive any outside funding. RESULTS: Intraobserver agreement for determining fracture level was near perfect (κ=0.94). Intraobserver agreement for AO classification, proposed treatment, neural canal penetration, and Denis classification were substantial (κ values, 0.75, 0.73, 0.71, and 0.69, respectively). Intraobserver agreement for loss of vertebral height and kyphosis were moderate (κ values, 0.55 and 0.45, respectively) CONCLUSIONS: Video clips of CT scans can be readily captured by a smartphone from a workstation-based PACS and then transmitted by use of the WhatsApp instant messaging application. Diagnosing, classifying, and proposing treatment of fractures of the thoracic and lumbar spine can be made with equal reliability by evaluating video clips of CT scans transmitted to a smartphone or by the standard method of viewing the CT scan on a workstation-based PACS. Evaluating video clips of CT scans transmitted to a smartphone is a readily accessible, simple, and inexpensive method. We believe that it can be reliably used for consultations between the emergency physicians or orthopedic or neurosurgical residents with offsite, on-call specialists. It might also enable rural orcommunity emergency department physicians to communicate more efficiently and effectively with surgeons in tertiary referral centers.

[THE EVOLUTION IN TREATING MENISCAL TEARS--FROM RESECTION TO SUTURING].

The meniscus has an important biomechanical role in the normal function of the knee including load bearing, shock absorption and joint stability. Tears of the meniscus are one of the common sports injuries. The knowledge that total meniscectomy causes early development of degenerative changes has raised the prevalence of meniscal tear repair in order to preserve as much as possible of the meniscal tissue. The type of tear (degenerative of traumatic), shape and location have a critical effect on healing ability after suture of the tear and thus will determine the treatment plan.

Heparanase procoagulant activity as a predictor of wound necrosis following diabetic foot amputation.

BACKGROUND: Trans-metatarsal operation to diabetic foot necrosis is a common procedure although only half of the patients do not need a second amputation due to surgery wound ischemia. No current tools are available for early prediction of surgery success and the clinical decision for a second operation may take weeks. Heparanase protein is involved in inflammation, angiogenesis and coagulation activation. The aim of the study was to evaluate heparanase level and procoagulant activity as an early predictor for success or failure of diabetic foot trans-metatarsal surgery. METHODS: The study group included 40 patients with diabetic foot necrosis requiring trans-metatarsal surgical intervention. Eighteen patients designated as necrotic group, developed post-surgery necrosis at the surgery wound within the first month, requiring a second more proximal amputation. Skin biopsies from the proximal surgery edge were stained for heparanase, tissue factor (TF), TF pathway inhibitor (TFPI) and by hematoxylin and eosin. Plasma samples were drawn pre-surgery and at 1h, 1week and 1month post-surgery. Samples were tested for heparanase levels by ELISA and TF+heparanase activity, TF activity and heparanase procoagulant activity. RESULTS: Skin biopsy staining did not predict subsequent necrosis. In the non-necrotic group a significant rise in TF+heparanase activity, heparanase activity and heparanase levels were observed 1h and 1week post-surgery. The most significant increase was in heparanase procoagulant activity at the time point of 1h post-surgery (P<0.0001). Pre-surgery TF activity was significantly lower in the non-necrotic group compared to the necrotic group (P<0.05). CONCLUSIONS: Measuring heparanase procoagulant activity pre-surgery and 1h post-surgery could potentially serve as an early tool to predict the procedure success. The present results broaden our understanding regarding early involvement of heparanase in the wound healing process.

Gait characteristics and quality of life perception of patients following tibial plateau fracture.

INTRODUCTION: The purpose of the current study was to evaluate the long-term functional outcome as measured by gait patterns and quality of life assessment of patients with high-energy tibial plateau fracture compared to matched controls. MATERIALS AND METHODS: Thirty-eight patients were evaluated in a case-controlled comparison. Twenty-two patients with tibial plateau fracture were evaluated after 3.1 (1.63) years (sd) from injury. Patients underwent a computerized spatiotemporal gait test and completed the SF-12 health survey. 16 healthy subjects, matched for age and gender served as a control group. The main outcome measures for this study were spatiotemporal gait characteristics, physical quality of life and mental quality of life. RESULTS: Significant differences were found in all gait parameters between patients with tibial plateau fracture and healthy controls. Patients with tibial plateau fracture walked slower by 18% compared to the control group (p < 0.001), had slower cadence by 8% compared (p = 0.002) to the control group and had shorter step length in the involved leg by 11% and in the uninvolved leg by 12% compared to the control group (p = 0.006 and p = 0.003, respectively). Patients with tibial plateau fracture also showed shorter single limb support (SLS) in the involved leg by 12% compared to the uninvolved leg and 5% in the uninvolved leg compared to the control group (p < 0.001 and p = 0.017, respectively). Significant differences were found in the Short Form (SF)-12 scores. Physical Health Score of patients with tibial plateau fracture was 65% lower compared to healthy controls (p < 0.001), and Mental Health Score of the patients was 40% lower compared to healthy controls (p < 0.001). Finally, significant correlations were found between SF-12 and gait patterns. CONCLUSION: Long-term deviations in gait and quality of life exist in patients following tibial plateau fracture. Patients following tibial plateau fracture present altered spatiotemporal gait patterns compared to healthy controls, as well as self-reported quality of life.

Recurrent episodes of micturition with expulsion of symphyseal plate screws following pelvic ring fixation: case report.

BACKGROUND: Based on a computer-assisted literature search, this case is the first description of repeated loosening of metallic internal fixation implants after pelvic ring stabilization, associated with intravesical metal migration and micturition with expulsion of two bone screws. CASE PRESENTATION: A 62-year old woman was seen after the urinary expulsion of a 6.5 mm diameter cancellous screw. About seven years earlier, she had been hit by a motorcyclist while crossing the street. On admission at the time of the initial injury, thoraco-abdominal computerized tomography with intravenous contrast material revealed a bladder injury and pelvic ring fractures. An anterior-posterior type injury to the pelvic ring was diagnosed with symphyseal pubis disruption, and widening of the left sacroiliac joint with an associated sacral fracture. Explorative laparotomy revealed two bladder lacerations of both the posterior and the anterior bladder wall, which were repaired primarily. Orthopedic surgeons reduced the pelvis and stabilized it with two plates and screws. Seven years after the original injury, the patient presented with recurrent abdominal pain after expelling a screw into the toilet while urinating. Planar radiographs showed only five of the original screws remaining in the two symphyseal plates, and all screws appeared to have loosened when compared to the original fixation radiograph. CONCLUSION: This clinical report emphasizes the importance of symphyseal plate positioning and the sequelae of imprecise positioning, especially postero-superiorly adjacent to the Retzius space. The presence of protruding metal prominences, even smooth ones like a plate corner or screw head, might endanger the bladder. When using superior plates, imprecise contouring may lead to plate edge protrusion which could damage the bladder even long after application.

Heparanase role in the treatment of avascular necrosis of femur head.

BACKGROUND: Idiopathic avascular necrosis (AVN) of bone causes significant morbidity in adults although the pathophysiology is unknown. The present treatment options include systemic biphosphonate therapy and local bone drilling decompression, ameliorating the healing process and their by render the weight bearing femur head less vulnerable to collapse. In the present study we demonstrate the involvement of heparanase in AVN and in the acceptable treatments. METHODS: 56 female rats were studied. In 8 control rats AVN was induced by ligamentum teres ligation of the right femur while the left femur remained intact. In the rest of the rats, in addition to right femur AVN, treatment was added by subcutaneous biphosphonate therapy, femoral head drilling or combination of the treatments. All rats were scarified after 6weeks. Immunostaining of the femur heads were performed to heparanase, tissue factor pathway inhibitor (TFPI), tissue factor (TF) and hematoxylin-eosin. RESULTS: Staining of heparanase, TFPI and TF were most prominent in the bone-marrow tissue of the femur heads. Staining by hematoxylin-eosin revealed damaged femur heads with prominent heparanase and TFPI staining in the femur with AVN compared to the contra lateral side of the same rat. No difference was found in the TF staining between the two sides. In the drilling and / or biphosphonate therapy groups, in contrast to the control group, femur heads were preserved with no significant difference in heparanase and TFPI staining between the two sides. CONCLUSIONS: Heparanase and TFPI are locally elevated in the process of AVN and are normalized by the acceptable treatments. Inhibition of heparanase by heparins can potentially improve the nowadays therapy modalities.

Correction of distal femoral valgus deformities in adolescents and young adults using minimally invasive fixator-assisted locking plating (FALP).

The treatment of distal femoral valgus deformities in skeletally mature patients might be a challenging surgical problem with significant morbidity. Treatment options are various and include osteotomy and external fixation, intramedullary nailing, and plating using standard and locking plates. We describe technical notes of minimally invasive technique of fixator-assisted plating using a supracondylar locking plate. During a period of 3 years, we operated on six patients (seven femurs) with distal femoral valgus deformities of different etiologies. All patients achieved correction of the deformities and started full weight bearing with radiographic evidence of union 6 weeks after correction. We believe that fixator-assisted locking plating has advantages over correction using external fixation and intramedullary nailing. This method of correction can be performed by a minimally invasive technique, precisely, and with minimal morbidity.

Increased heparanase level and procoagulant activity in orthopedic surgery patients receiving prophylactic dose of enoxaparin.

BACKGROUND: Orthopedic hip and knee surgeries are followed by a hypercoagulable state. Heparanase is implicated in inflammation, coagulation activation and angiogenesis. Recently, heparanase was shown to directly interact with tissue factor (TF) and to enhance the generation of factor Xa (Nadir et al., Haematologica, 2010). In addition, an assay assessing heparanase procoagulant activity has been lately developed (Nadir et al., Thromb Res, 2011). In the present study heparanase level and procoagulant activity in patients undergoing orthopedic surgery were assessed. METHODS: The study group included 50 orthopedic patients. 31 patients underwent hip surgery and 19 had knee operation. 15 individuals suffered from traumatic hip fractures and 35 had osteoarthrosis of hip or knee joints. All patients received prophylactic dose of enoxaparin starting 6-8 hours post operation and lasting for 5 weeks. Plasma samples were drawn preoperatively and at 1 hour, 1 week and 1 month post operation. Samples were tested for heparanase levels by ELISA and TF/heparanase complex activity, TF activity, heparanase procoagulant activity, factor Xa and thrombin levels using chromogenic substrates. RESULTS: Heparanase levels were significantly higher 1 hour and 1 week post operatively compared to preoperative levels (p<0.05, p<0.005, respectively). The most dramatic changes were observed in heparanase procoagulant activity reaching a 2 fold increase 1 week postoperatively and 1.7 fold increase 1month after surgery (p<0.0001, p<0.0001, respectively). Levels of factor Xa and thrombin did not significantly change. CONCLUSIONS: Heparanase is involved in coagulation activation of orthopedic surgery patients. Heparanase procoagulant activity is highest 1 week postoperatively and remains high 1month after operation. Considering extending prophylactic anticoagulant therapy or evaluating heparanase procoagulant activity may potentially prevent late thrombotic events.

Use of a new exsanguination tourniquet in internal fixation of distal radius fractures.

We describe our experience using a new device that results in a bloodless field in open repair of distal radius fractures. The device, an exsanguinating tourniquet (HemaClear model/40, OHK Medical Devices, Haifa, Israel), replaces the traditional methods of limb elevation, Esmarch bandaging, pneumatic tourniquet pressurizing and the associated components. HemaClear/40 is an elastic silicon ring with a tubular elastic sleeve rolled onto it. The device has attached straps that, when pulled, unroll the sleeve, rolling the ring mesially on the limb. The pressure exerted by rolling HemaClear/40 is supra-systolic thereby exsanguinating the limb and occluding the arterial inflow. Our experience in 49 patients demonstrated quick application, superior exsanguination and that the device could be placed on the forearm instead of the upper arm. No side effects or complications were noted. In our opinion, the fact that HemaClear/40 is a sterile, single-patient device makes it superior over the traditional technology.

Prevention of distortion of vascular deprivation-induced osteonecrosis of the rat femoral head by treatment with alendronate.

INTRODUCTION: In animals with a disrupted blood supply and drainage of the femoral head, the dead epiphyseal bone undergoes osteoclastic osteolysis and is replaced by newly synthesized, immature, and weak bone, which cannot withstand the daily loads and, therefore, the articular surface caves in. METHODS: Female Sprague-Dawley rats with interrupted blood circulation of the femoral head were treated with alendronate and compared to controls. RESULTS: There was no distortion of the femoral heads in the alendronate-treated animals. INTERPRETATION: Alendronate medication interferes with osteoclastic activities, slowing down bone turnover. These observations verify our hypothesis that osteoclastic activity is detrimental to the conservation of a hemispherical femoral head because of the rapidly occurring replacement of the dead by living tissues. Hence, halting the activities of the osteoclasts by alendronate stops the hasty new bone formation which is responsible for early femoral capital disfigurement.

Cerebral microemboli during hip fracture fixation: a prospective study.

BACKGROUND: Recent studies have shown that cerebral fat microembolism takes place during surgery for hip or knee replacement. In this study, we examined the occurrence of cerebral microembolism, solid or gas, during a standard procedure of hip fracture fixation. METHODS: This was a prospective study of patients who underwent urgent surgery with a dynamic hip screw for hip fracture fixation. During surgery, patients were monitored with transcranial Doppler for detection of microemboli from right and left middle cerebral arteries. RESULTS: Twenty-two patients were included in the study; their median age was 82 yr (range, 51-97 yr). In nine (41%) patients, high intensity transient signals were recorded, indicating microemboli passage in the middle cerebral arteries. All nine patients had signals of both solid and gas emboli. One of these nine patients had a postoperative cerebrovascular accident. CONCLUSIONS: The incidence of cerebral microemboli during urgent surgery for hip fracture fixation is considerable. This phenomenon is not confined to hip or knee replacement surgery. The clinical implications of this finding require further investigation.

Treatment of Graf's ultrasound class III and IV hips using Pavlik's method.

UNLABELLED: When Pavlik introduced his method of treating congenital dislocation of the hip, he emphasized reducing the rate of osteonecrosis. Graf's method of sonographic evaluation afforded earlier accurate diagnosis and subsequent treatment of developmental dysplasia of the hip. To ascertain whether treatment duration, gender, age at diagnosis, clinical stability, and/or treatment onset correlate with the risk of osteonecrosis in Graf Type III or IV hips, we clinically and sonographically screened 18,067 neonates (36,134 hips) for developmental dysplasia of the hip over a 4-year period; 151 had Graf Type III or IV hips, and 78 of these were treated by us and had known outcomes. Of these 78 hips, 65 (0.18%) had Graf Type III and 13 (0.036%) had Graf Type IV hips. Sixteen of the 65 Type III hips (25%) reduced spontaneously. Using Pavlik's method, reduction was achieved in 46 of 65 (88.5%) Type III hips and eight of 13 Type IV hips. None of the hips treated exclusively by Pavlik's method developed osteonecrosis. Thus, the method achieves one of Pavlik's original goals of decreasing osteonecrosis incidence to close to zero. LEVEL OF EVIDENCE: Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.