Effects of the COVID-19 pandemic on the outcome and mortality of patients with diabetic foot ulcer.

The outbreak of the coronavirus disease 2019 (COVID-19) led to events that significantly impaired the treatment and management of patients with chronic diabetes. Therefore, elective treatments at hospitals were cancelled and patients with chronic ailments were instructed to stay at home and minimise the time spent in public areas. The second was due to COVID-19-induced anxiety that deterred many patients from seeking care and adhering to periodic out-patient visits. In this study, we examined the short-term effects of the COVID-19 pandemic on patients with chronic diabetes who suffered from contaminated diabetic ulcers. We conducted a retrospective study with patients who had undergone amputations following diabetic ulcers during 2019-2020. The research group included diabetic amputees during the COVID-19 outbreak period ranging from March 2020 to December 2020. The control group included diabetic amputees from the corresponding period in 2019. Using the Wagner Scale, we measured the difference in the severity of ulcers upon the patient's initial admission. Additionally, we examined patient survival rates based on the size of amputations, by specifically focusing on the period between 1- and 6-months post-surgery. The results failed to suggest a clear and statistically significant worsening trend in the condition of patients in the research and control groups. Due to public lockdowns, transportation restrictions, scarcity of healthcare staff, and reduced adherence to exposure anxiety, patients with diabetic foot ulcers received inferior medical care during the COVID-19 pandemic. However, this study could not find a statistically significant difference in the mortality and major amputation rates in patients with diabetic ulcer before and during the pandemic. The health system should incorporate the existing institutional and technological recommendations to facilitate care and follow-up of patients with diabetic foot ulcers during the current and future pandemics.

Hand function following accidental automatic animal syringe injector injuries.

Accidental self-injection injury is a common occurrence among veterinary and farm workers handling automatic syringe injectors. Most of the time, these injuries are asymptomatic or cause self-resolving mild symptoms, but these injuries may lead to significant morbidity. The aim of the study was to evaluate hand function after inadvertent injection of a poultry influenza or cholera vaccine in patients admitted to our department with infection. We retrospectively gathered data from admission to last follow-up. Functional assessment and physical exam of the hand were done at each stage by either an orthopedic resident or a fellowship-trained hand surgeon. The exam included evaluation of sensation using monofilament, joint range of motion using a goniometer, and a Quick DASH questionnaire. The study included 21 patients, all men, with a mean age of 33.4 years (range 23-44). Of the 21 patients only eight had attended all follow-ups. All patients had injury to the non-dominant hand. Seventeen of 21 of the cases had finger injuries, out of which 11 involved the thumb. The mean hospitalization time was 3.75 days (1-10). Of the 21 patients, seven underwent surgery to drain a collection during hospitalization. Seven out of eight patients had lowest disability scores on Quick Dash questionnaire. Three out of eight patients lost superficial sensation at the tip of the finger. The largest loss of range of motion was found in the distal interphalangeal joint in the finger or interphalangeal joint in the thumb, especially following surgical drainage. Of the eight patients presenting for follow-up, most had returned to the same job. Hand function was normal, as expressed in a DASH questionnaire. Sensory examination demonstrated that the sensation was almost unaffected over the injured finger. Range of motion of the joint closest to the injection site was usually the most impaired. Patients who underwent surgical drainage had a reduced range of motion.

The optimal duration for the wrinkle test in a clinical setting.

To determine the time needed or the development of a positive result on the wrinkle test among patients with complete laceration of a digital nerve in a clinical setting. We prospectively recruited 20 patients who had undergone surgery for digital nerve laceration. The wrinkle test was conducted at a follow-up session up to 2 months after surgery, and the time to a positive wrinkling result was recorded. The wrinkle test was compared between the patient's injured versus uninjured contralateral finger. The average time required for a positive result on the wrinkle test was 24.5 min (± 11), with 25% patients requiring 40 min to obtain a positive result. When evaluating a patient with digital nerve injury in a "non-laboratory" environment, the wrinkle test may require up to 40 min to obtain a positive result. Our study suggests that if tests are completed following the generally accepted time limit reported in the literature (30 min), up to 25% of tests may produce false negative results.

Successful reconstruction of natural femoral anteversion using a short femoral stem in total hip arthroplasty surgery.

OBJECTIVE: Total hip arthroplasty (THA) involves postoperative risks, such as thigh pain, periprosthetic fractures, and stress yielding. Short, anatomical, metaphyseal-fitting, cementless femoral stems were developed to reduce these postoperative risks. This study aimed to examine the "MiniMAX" prosthesis, which is a new generation, short, anatomical femoral stem made by Medacta. METHODS: Patients underwent a low-dose computed tomography scan. Femoral anteversion was measured. We assessed the position and anteversion of the femoral component and compared them with the unoperated side. We also assessed the patients' satisfaction and functional levels at 6 months postsurgery using the Harris Hip Score (HHS) and the Oxford Hip Score (OHS). RESULTS: Nineteen individuals were recruited in this study. We found no significant difference in femoral anteversion between the operated hip and the native hip. Using the HHS and OHS questionnaires, we found clinical improvement in the 6-month postoperative scores compared with the preoperative scores. DISCUSSION: The new-generation, short, anatomical femoral stem made by Medacta is successful in reproducing natural femoral anteversion, while also improving patients' functioning and lifestyle. Future large-scale, prospective comparison trials are required to further investigate this topic.

Nail Puncture Wound Through a Rubber-Soled Shoe: Should We Take Every Patient to the Operating Room?

Nail puncture wounds through rubber-soled shoes, when presenting acutely, have a deceivingly benign appearance. High index of suspicion for a retained rubber piece should be maintained by the physician. This study investigates whether preoperative ultrasound examination can rule out a foreign body and reduce the need for surgery. It is a retrospective cohort of 125 patients with deep nail puncture wounds through a rubber-soled shoe, who underwent surgical exploration between 2008 and 2018. All patients had a preoperative ultrasound examination for detection of a rubber foreign body. The patients' median age was 29, and 112 (89.6%) were males. Median time of presentation was 1 day, but there were patients who presented up to 90 days after injury (mean 5.1 ± 15.6 days). Foreign bodies, ranging 1 to 4 mm in diameter, were surgically removed in 37 (29.6%) patients. Only 16 of these patients had a positive preoperative ultrasound examination, corresponding to sensitivity of 43.2%. Specificity of the ultrasound examination was 95%. Ultrasound examination has low sensitivity for detection of foreign bodies following a puncture wound of the foot. This is attributable to the small size of the foreign bodies in this scenario and to the complexity of sonography in this location. We conclude that ultrasound cannot be used to rule out foreign body in the foot, and should not be relied on when deciding to avoid surgery. Nevertheless, it can be a helpful adjunct preoperatively, as an assessment of the foreign body size and location.

Recommendations for Orthopedic Surgeons during the COVID-19 Pandemic.

BACKGROUND: Toward the end of 2019, the coronavirus disease-2019 (COVID-19) pandemic began to create turmoil for global health organizations. The illness, caused by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), spreads by droplets and fomites and can rapidly lead to life-threatening lung disease, especially for the old and those with health co-morbidities. Treating orthopedic patients, who presented with COVID-19 while avoiding nosocomial transmission, became of paramount importance. OBJECTIVES: To present relevant methods for pandemic control and hospital accommodation with emphasis on orthopedic surgery. METHODS: We searched search PubMed and Google Scholar electronic databases using the following keywords: COVID-19, SARS-CoV-2, screening tools, personal protective equipment, and surgery triage. RESULTS: We included 25 records in our analysis. The recommendations from these records were divided into the following categories: COVID-19 disease, managing orthopedic surgery in the COVID-19 era, general institution precautions, triage of orthopedic surgeries, preoperative assessment, surgical room setting, personal protection equipment, anesthesia, orthopedic surgery technical precautions, and department stay and rehabilitation. CONCLUSIONS: Special accommodations tailored for each medical facility, based on disease burden and available resources can improve patient and staff safety and reduce elective surgery cancellations. This article will assist orthopedic surgeons during the COVID-19 medical crisis, and possibly for future pandemics.

Pediatric Femoral Neck Fractures after Sliding in a Water Slide: A Case Report of Two Patients.

INTRODUCTION: In contrast to adults, fractures of the neck of femur in children are relatively rare. The commonly described mechanism of injury is high energy trauma. Treatment options are almost always surgical. Prognosis, which entails relatively high rates of complications, varies with specific anatomic location, time to surgery, and reduction quality. CASE REPORT: We describe two cases of 10- and 12-year-old girls who suffered a fracture of the neck of the femur, Delbet Type II and Type III, respectively, due to a suspected hyper-abduction injury while sliding on a water slide. Both patients were treated surgically, with the younger one developing signs of femoral head avascular necrosis a year postoperatively. CONCLUSION: Children with pain and an inability to bear weight after water sliding together with an adult companion at their backs should raise suspicion among medical staff of a femoral neck fracture. Prompt pediatric orthopedic consultation and treatment are needed in case of fracture diagnosis to reduce the risk of complications.

Perilunate Dislocation Above the Age of 65 Years: Case Series and Review of Literature.

INTRODUCTION: Perilunate and fracture dislocations predominantly follow a high-energy mechanism. Perilunate dislocations have an incidence of 0.5/105 individuals/year, occurring at a mean age of 26 years and are frequently seen in men. This study aimed to describe the characteristics of this injury in elderly population of patients using literature review and our experience with four cases aged >65 years. MATERIALS AND METHODS: We treated four patients with perilunate dislocation aged >65 years. All the patients' medical records were reviewed retrospectively. A literature review for case studies of perilunate dislocation was conducted with the purpose of finding cases including patients aged >65 years. RESULTS: Three of our patients had injuries that were missed in the first visit in the emergency department. The mechanism of injury was high energy in only two patients. Two patients had posterior perilunate dislocation, while the other two had transradial perilunate dislocation. Three patients were available for follow-up. The overall outcome was satisfaction according the Mayo wrist score and minimal disability according to the Disabilities of the Arm, Shoulder and Hand score. All patients reported that pain was absent and they were able to return to their regular activities. The literature review found only seven papers documenting treatment of patients aged >65 years. DISCUSSION: Perilunate dislocation is extremely rare in the population aged >65 years. Although the rate of missed diagnosis in our cohort was extremely high, the overall satisfaction and return to function was high. CONCLUSIONS: This case series and literature review highlight the unique characteristics of this injury in the age group of patients aged >65 years. Although perilunate dislocation in patients aged >65 years is rare, clinicians should be aware of the presentation of this condition in the elderly.

User Assessment of a Novel Suspension for a Wheelchair-A Prospective, Randomized, Double Blind Trial.

BACKGROUND: Many Wheelchair users experience adverse effects specific to their situation, some of which might be avoided if suspension systems are integrated into the wheelchair. OBJECTIVES: Our study aimed to compare the user experience using a novel wheelchair suspension system with normal wheels. We tried to quantify the user feelings and impressions while using the different wheels. STUDY DESIGN: Double blinded comparative randomized study. METHODS: The patients were randomized into 2 groups. One used shock absorbing wheels, and the other group had a set of standard wheels with the same exact wheelchairs. The patients were taken to a daily trip by the caregivers and given questionnaires in the second and fourth days. On the morning of the third day the wheels were interchanged, creating a cross over between the groups. We collected general and medical information from the participants. The main outcome measures were the questionnaires filled by the patients and the caregivers aiming to quantify the user experience with the suspension equipped wheels. RESULTS: Statistical significance was reached in 2 questions referred to the patients: "In general-During the ride I didn't feel the bumps" and "I feel very confident when riding the chair" and in one question referred to the caregiver-"It was easy to push the chair in suboptimal ground." CONCLUSIONS: We conclude that the shock absorbing system provided a better user experience in the immediate term than standard wheels. Further study is needed to assess the long-term implications.

The Paley ilioischial limb modification of the Dega osteotomy.

Background: We aim to describe a modified Dega osteotomy technique in detail, emphasizing its eventual advantages in comparison to the original Dega osteotomy and 'San Diego' modification. We also present our related literature review on various osteotomy techniques. Methods: We reviewed the radiological indices of 27 dysplastic hips in 25 children with cerebral palsy and developmental dislocation of the hips (9 boys, 16 girls; mean age, 5 years) who underwent a modified Dega osteotomy according to Paley. Results: Comparing the radiological indices results between our patients and those reported by the various authors in the literature, the data are almost identical. Conclusions: The modified Dega osteotomy is the only technique wherein all two limbs of the triradiate cartilage are true, which becomes a single hinge where the osteotomy turns. Despite the similar results in the radiological indices between our patients and those in the literature, we still consider that the entire triradiate cartilage is a better hinge point for the iliac osteotomy. The difference between the osteotomy adopted in our institution and the modality described by most authors in the literature is that the latter mostly ignore or miss the ischial limb of the triradiate cartilage.

Relationship between electrodiagnostic findings and sleep disturbance in carpal tunnel syndrome: A controlled objective and subjective study.

OBJECTIVE: This controlled objective and subjective study aimed to evaluate the relationship between insomnia severity and electrodiagnostic findings in patients with carpal tunnel syndrome (CTS). METHODS: Twenty-one patients with an established clinical and electrodiagnostic diagnosis of CTS before surgery were included. Sleep characteristics were monitored objectively over 4 to 9 nights by means of actigraphy. On the following morning, participants completed a sleep log that conveyed their subjective impressions of how they had slept. All patients also completed the Insomnia Severity Index questionnaire. The correlation of these findings with patients' motor latency and sensory latency was evaluated using Spearman correlation analysis. RESULTS: We found no correlation between sensory or motor latencies and all sleep measures. CONCLUSION: Electrodiagnostic findings and sleep severity in patients with CTS appear to be independent measures, and they do not correlate with each other.

The Utility of Diagnostic Tests for Digital Nerve Injury.

PURPOSE: The purpose of this study was to present the sensitivity and specificity of 6 clinical tests for the diagnosis of digital nerve injury. The clinical tests are as follows: light touch, pinprick, static and dynamic 2-point discrimination (D2PD), Semmes-Weinstein monofilament, and wrinkle test. METHODS: We reviewed the charts of all the patients who were admitted to our department with hand lacerations and/or suspicions of digital nerve injury that were examined before surgery with the 6-sensation test, comparing the results to the surgical findings. RESULTS: The study included 70 patients with 85 injured nerves overall. Of the 85 nerves, 51 were found with full cut, 9 with partial cut, and 25 with no cut. Only 2 variables were significantly associated with the study outcome: D2PD > 4 (P = 0.0141, odds ratio = 3.9, 95% confidence interval = 1.3-11.8, sensitivity = 80.7%, specificity = 48%) and wrinkle test (P = 0.0098, odds ratio = 4.0, 95% confidence interval = 1.4-11.6, sensitivity = 69.5%, specificity = 62.5%).Multivariable logistic regression included these variables and revealed the predictive probability for a nerve injury to be 92% if both risk factors exist and 43% if none of these risk factors exist. If one risk factor exists, the predictive probability for a cut is still very high (75%). CONCLUSIONS: The combination of positive wrinkle test and D2PD > 4 gave a predictive probability for a nerve injury as 92% in the cases in our study and should be considered in the evaluation of patients with hand lacerations and suspicions of digital nerve injury.

Autologous cell-coated particles for the treatment of segmental bone defects-a new cell therapy approach.

BACKGROUND: Adipose tissue-derived mesenchymal stem cells (AT-MSCs) are one of the most potent adult stem cells, capable of differentiating into bone, cartilage, adipose, muscle, and others. An innovative autologous AT-MSC-derived cell-based product (BonoFill-II) for bone tissue regeneration was developed to be suited as a bone graft for segmental bone defects. METHODS: BonoFill-II was transplanted into 8 sheep with 3.2-cm full cortex segmental defect formed in the tibia. Bone regeneration was followed by X-ray radiographs for 12 weeks. At experiment termination, the healed tibia bones were analyzed by computed tomography, histology, and mechanical tests. RESULTS: Our results indicate that one dose of BonoFill-II injectable formula led to an extensive bone growth within the transplantation site and to a complete closure of the critical gap in the sheep's tibia in a relatively short time (8-12 weeks), with no inflammation and no other signs of graft rejection. This new and innovative product opens new prospects for the treatment of long bone defects. CONCLUSIONS: Injection of BonoFill-II (an innovative autologous cell therapy product for bone tissue regeneration) into a critical size segmental defect model (3.2 cm), generated in the sheep tibia, achieved full bridging of the gap in an extremely short period (8-12 weeks).

Congenital pseudoarthrosis of the clavicle: Should we reconsider timing and fixation method?

BACKGROUND: Congenital pseudoarthrosis of the clavicle (CPC) is rare and may require treatment, usually because of an unacceptable appearance or occasionally because of pain in an adolescent patient. Spontaneous union is unknown, and consequently any desired union requires open reduction and bone grafting. Many authors recommend performing the operation at the age of 3-5 years and using different fixation methods. We present our experience with three cases and literature review in an attempt to further elucidate the appropriate timing of the procedure and the fixation method. METHODS: This was a retrospective review of three cases presenting with pseudoarthrosis of the clavicle. All cases were treated by curettage of the pseudoarthrosis, with the void filled using full-thickness ileac crest autologous bone graft and bridging plate-one compression and two anatomical, at different ages. We performed a literature review with emphasis on timing of the procedure, fixation method and complications. RESULTS: All patients healed with good callus formation. One patient (5-year-old female treated using a compression plate) experienced overlying skin irritation and underwent removal of the plate. There were no restriction of movement, pain or any other complaint on the final follow-up. We did not find any difference in the operating complexity at different ages, but when a compression plate was used, it had to be removed later due to bulging of the plate. DISCUSSION: No clinical difference was observed between earlier and late operation. Therefore, we suggest performing a curettage of the pseudoarthrosis, gapping the void using autologous bone graft, and using an anatomical bridging plate.

Open reduction and internal fixation of intra-articular distal radius fractures under wide-awake local anesthesia with no tourniquet.

Objective The use of wide-awake local anesthesia with no tourniquet (WALANT) is becoming an excellent alternative for elective hand surgeries and hand surgeries involving minor trauma. Although the use of WALANT for some soft tissue surgeries has become the state of the art, data regarding bony procedures, such as fracture management, under WALANT are limited. This study was performed to assess the WALANT technique for open reduction and internal fixation of distal radius fractures. Methods Five patients with displaced distal radius fractures were enrolled in the study. WALANT was carried out about 30 minutes prior to the first incision. Surgery was performed in the normal fashion, and the fractures were fixed using anatomic locking plates. After surgery, the patients were admitted overnight for observation and pain assessment, and they were discharged within 24 hours postoperatively. Intraoperative and postoperative complications were recorded. Follow-up was performed in our outpatient clinic. No abnormalities were recorded. Results All patients underwent a successful painless surgery. No extra bleeding or other complications were recorded. Conclusion The WALANT technique offers a simple and safe alternative to traditional anesthetic techniques for open reduction and plating of distal radius fractures.

Outcomes of French's Corrective Osteotomy of the Humerus for Cubitus Varus Deformity in Children.

BACKGROUND: Supracondylar humerus fractures are the most common elbow fractures in the pediatric population. OBJECTIVES: To evaluate the outcomes of French's corrective osteotomy for correction of post-traumatic cubitus varus deformity in children. METHODS: We conducted a retrospective review of medical charts of all patients who had undergone French's corrective osteotomy in our institution from 1998 to 2012. We recorded range of motion, cosmetic deformity, carrying angle, lateral cortex prominence index, hyperextension, and lateral cortex step before and after the surgery. RESULTS: Seven patients were enrolled the study. Average follow-up time was 4.6 years (range 2-9 years). An average of 18.3º of limited flexion (range 5º-35º) compared to the healthy elbow was recorded in three patients. Lateral condylar prominence was recorded in one patient. The average preoperative carrying angle was -20.5º (range -15º-30º) and postoperative angle was 9.6º (range 7º-13º). In comparison, the average carrying angle in the healthy elbow was 8.5º (range 4º-13º). No lateral cortex prominence was recorded. An average of 27.5º (range 15º-35º) of hyperextension of the distal fragment was recorded immediately postoperatively in four patients; however, during postoperative follow-up, the hyperextension was corrected spontaneously in all patients. CONCLUSIONS: As described by French, osteotomy has the ability to correct the varus deformity only in the coronal plane. However, our research supports the assumption that hyperextension in the sagittal plane might be corrected spontaneously.

The effectiveness of splinting and surgery on sleep disturbance in carpal tunnel syndrome.

This controlled prospective study assessed the effectiveness of night splinting compared with non-splinting and surgery for severity of insomnia in patients with carpal tunnel syndrome. Sleep characteristics were observed for several days without a brace, with a brace and after surgery. The sleep measurements included the use of an actigraph worn on the wrist during night, a 'sleep log' that conveyed subjective impressions as to how the patient had slept and a short insomnia instrument, the Insomnia Severity Index. The Insomnia Severity Index scores showed that a night splint significantly improved insomnia symptoms compared with no splinting, and surgery significantly improved insomnia symptoms compared with splinting. The sleep log scores showed that the sleep quality and the number of awakenings when a splint was not worn were significantly different from the scores with the splint and the scores after surgery but showed no differences between splint and surgery. The actigraph did not show any significant differences between the treatment methods. LEVEL OF EVIDENCE: III.

Dupuytren's Contracture: Current Treatment Methods.

BACKGROUND: Dupuytren's disease is a common benign fibromatosis of the palmar and digital fascia. The exact pathophysiology and epidemiology of this condition have not been entirely identified. Pathologic fibrous bands cause a flexion contracture of the metacarpal phalangeal joints and proximal interphalangeal joint. Treatment includes fasciectomy, needle fasciotomy, and enzymatic fasciectomy.

Upper extremity open fractures in hospitalized road traffic accident patients: adult versus pediatric cases.

BACKGROUND: Fractures in pediatrics show epidemiological characteristics which are different from fractures in adults. The objective of this study was to examine the injury profiles of open upper extremity fractures (UEFs) in all modes of injury related to road traffic accidents (RTAs) in adult and pediatric hospitalized patients. METHODS: Data on 103,465 RTA patients between 1997 and 2013 whose records were entered in a centralized country trauma database were reviewed. Data on open UEFs related to mode of injury (car, motorcycle, bicycle, and pedestrian) was compared between adult (18+ years) and pediatric (0-17 years) RTA patients. RESULTS: Of 103,465 RTA cases, 17,263 (16.7%) had UEFs. Of 73,087 adults, 13,237 (18.1%) included UEFs and of 30,378 pediatric cases, 4026 (13.2%) included UEFs (p < 0.0001). Of 17,263 cases with UEFs, we reviewed 22,132 fractures with 2, 743 (12.4%) open fractures. Adults had a greater risk for open fractures (2221, 13%) than the pediatric cases (522, 10.3%) (p < 0.0001). Overall, of a total of 22,132 UEFs, most of the fractures were in the radius (22.8%), humerus (20.3%), clavicle (17.5%), and ulna (15.4%). The adult pedestrian group had a significantly higher risk for open UEFs than the pediatric group (11 vs 8%, p = 0.0012). CONCLUSIONS: This study demonstrates the difference between adult and pediatric open fractures in hospitalized RTAs. We showed that adults had a greater risk for open UEFs compared to children, and the adult pedestrian group particularly had a significantly higher risk for open UEFs than the pediatric group.

Computed navigated total knee arthroplasty compared to computed tomography scans.

BACKGROUND: Successful total knee arthroplasty (TKA) includes accurate alignment. Controversy remains as to whether computer-navigated TKA improves the overall result and clinical outcome. Our aim is to compare the limb alignment and prosthesis positioning according to the pre- and postoperative computed tomography (CT) scans with the data collected from the navigation system. METHODS: We compared the pre- and postoperative limb alignments and prosthesis alignment provided by the Orthopilot navigation system, Aesculap®, with CT scans measured by the Traumacad® software of 70 TKAs. RESULTS: A positive correlation with statistical significance (P=0.00001, r=0.874) between the navigation system data and the CT images was found. Mean femoral cut was five degrees (valgus), and mean tibial cut was one degree (varus). Our study revealed that the navigation system assisted the surgeon to implant the prosthesis at a good acceptable alignment. CONCLUSION: We found that the navigation system is accurate and correlates to the pre- and postoperative CT scans. Furthermore, the navigation system can assist the surgeon to achieve good limb alignment and cutting planes of the prosthesis.